Cost minimization analysis of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants.

BACKGROUND: Trials describing 4-12 week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R-transplants), may be limited in application by costs and delayed access to expensive DAAs. A short prophylactic strategy may be safer and cost-effective. Here, we report a cost minimization analysis using the health system perspective to determine the least expensive DAA regimen, using available published strategies. OBJECTIVES: To conduct cost-minimization analyses (CMAs) from the health system perspective of four DAA regimens to prevent and/or treat HCV transmission from D+/R-kidney transplants. METHODS: CMAs comparing 4 strategies: 1) 7-day prophylaxis with generic sofosbuvir/velpatasvir (SOF/VEL), with 12-week branded glecaprevir/pibrentasvir (G/P) for those with transmission; 2) 8-day branded G/P prophylaxis, with 12-week branded SOF/VEL/voxilaprevir for those with transmission; 3) 4-week perioperative generic SOF/VEL prophylaxis, with 12-week branded G/P for those with transmission; and 4) 8-week branded G/P "transmit-and-treat." We included data from published literature to estimate the probability of viral transmission in patients who received DAA prophylaxis, and assumed a 100% transmission rate for those who received the "transmit-and-treat" approach. RESULTS: In base-case analyses, strategies 1 (expected cost [EC]: $2326) and 2 (expected cost: $2646) were less expensive than strategies 3 (EC: $4859) and 4 (EC: $18,525). Threshold analyses for 7-day SOF/VEL versus 8-day G/P suggested that there were reasonable input levels at which the 8-day strategy may be least costly. The threshold values for the SOF/VEL prophylaxis strategies (7-day vs. 4- week) indicated that the 4-week strategy is unlikely to be less costly under any reasonable value of the input variables. CONCLUSIONS: Short duration DAA prophylaxis using 7 days of SOF/VEL or 8 days of G/P has the potential to yield significant cost savings for D+/R- kidney transplants.

A Retrospective Cohort Evaluation of a Pharmacist-Led Approach for Transitioning Patients to an Angiotensin Receptor-Neprilysin Inhibitor.

Background: Heart failure guidelines recommend replacing an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) with an angiotensin receptor neprilysin inhibitor (ARNI) to reduce morbidity and mortality in NYHA Class II-III patients with reduced ejection fraction (HFrEF). Objective: This study aims to determine if a pharmacist-led outpatient ARNI replacement and titration program led to more patients achieving target doses of ARNI compared to usual care. Methods: A single health system, retrospective electronic medical record review identified 791 patients with active ARNI prescriptions and at least two outpatient cardiology visits with a pharmacist or usual care provider between January 2015 through September 2018. The primary outcome was the percentage of patients who achieved a target ARNI dose of 97/103 mg twice daily. The secondary outcomes were the median dose achieved, number of visits required to achieve target dose, hospitalizations, and all-cause death. Results: ARNI was initiated and continued by a pharmacist in 64 patients and 727 by usual care. More patients in the pharmacist group, 60.9% (n = 39), achieved target dose vs. 18.0% (n = 131) of patients managed by usual care (95% CI, 0.31-0.55, p < 0.0001). The pharmacist group also had higher median total daily dose of ARNI (200 mg (IQR = 300) vs 100 mg (IQR = 100), p < 0.0001) and more likely to achieve a higher total daily dose in fewer visits. Conclusions: An advanced practice provider pharmacist-led outpatient ARNI replacement and titration program was more effective in achieving target doses of ARNI in HFrEF patients as compared to usual care.

Patterns of school and college of pharmacy engagement in addressing the opioid crisis.

INTRODUCTION: The American Association of Colleges of Pharmacy (AACP) has emphasized the need to prepare pharmacy students for practicing amidst the opioid crisis. This research aimed to identify patterns and predictors of pharmacy program participation in skills-based education, research, and service activities designed to address this crisis. METHODS: Opioid-related activities were identified from the AACP opioid-related activities database and classified by two independent reviewers. The final activities included: (1) direct participation in drug disposal and/or naloxone outreach, (2) opioid-focused research, and (3) skills-based training in the doctor of pharmacy curriculum. Latent class analysis was used to identify classes of program involvement in these activities. Differences in class membership based on program and geographic characteristics were examined using multivariable logistic regression. RESULTS: Of the 106 schools included, a minority reported opioid-focused research (38.7%), drug disposal or naloxone outreach (30.2%), or hands-on learning (22.6%). A "highly engaged" class (34.9%) and a "limited engagement" class (65.1%) were identified. "Highly engaged" programs were more likely to report opioid-related research (65.9% vs. 24.6%, P < .001), drug disposal or naloxone outreach events (86.5% vs. 0%, P < .001), and skills-based education (40.5% vs. 13%, P = .001) than "limited engagement" programs. No school or geographic factors were significantly associated with class membership. CONCLUSIONS: Nearly two-thirds of schools and colleges of pharmacy reported limited involvement in skills-based education, research, and outreach efforts. Future research should explore other predictors of school-level opioid-related activities, including faculty expertise and institutional priorities.

Coverage of the opioid crisis in national network television news from 2000-2020: A content analysis.

Background: News coverage has both negatively and positively influenced public awareness and perceptions surrounding the opioid crisis. This study aimed to describe and analyze national network television news framing of the scope and impact of the opioid crisis in the United States. Methods: We performed a retrospective content analysis on national network television evening news segments covering the opioid crisis from 1/2000 to 8/2020, which were obtained from the Vanderbilt Television News Archive. The database was queried for: opioid epidemic, oxycontin, heroin, fentanyl, and naloxone. Two independent reviewers quantitatively coded segment characteristics, including theme, geographic location, opioids mentioned, strategies for combatting the epidemic discussed, interviews conducted, and patient demographics. Changes in segment characteristics over time were analyzed using chi-square analyses and Fisher's exact tests. Results: News segments (N = 191) most commonly provided an overview of the epidemic (55.5%) and/or conveyed personal stories (40.3%). Prescription opioids (59.7%) and heroin (62.8%) were more often referenced than fentanyl (17.8%); the focus on heroin peaked in 2011-2015 (84.8%), while references to fentanyl significantly increased over time (p = 0.021). The most frequently interviewed people included patients with opioid use disorder (OUD) (47.1%), healthcare providers (36.7%), family members/friends (31.9%), and law enforcement (30.9%). Most of the featured patients with OUD were male (63.0%), white (88.4%), and young (< 40 years) adults (77.9%). Coverage of the crisis peaked in 2016. Conclusions: Evening news segments' emphasis on personal stories, while emotionally compelling, came at the cost of thematically-framed coverage that may improve public understanding of the complexities of the epidemic. The depiction of primarily white, young adult patients with OUD revealed a need for a greater emphasis in the news on underrepresented minorities and older adults, as these populations face additional stigma and disparities in OUD treatment initiation and retention.

The cost-effectiveness of pharmacist-physician collaborative care models vs usual care on time in target systolic blood pressure range in patients with hypertension: a payer perspective.

BACKGROUND: Hypertension is highly prevalent in the United States, affecting nearly half of all adults (43%). Studies have shown that pharmacist-physician collaborative care models (PPCCMs) for hypertension management significantly improve blood pressure (BP) control rates and provide consistent control of BP. Time in target range (TTR) for systolic BP is a novel measure of BP control consistency that is independently associated with decreased cardiovascular risk. There is no evidence that observed improvement in TTR for systolic BP with a PPCCM is cost-effective. OBJECTIVE: To compare the cost-effectiveness of a PPCCM with usual care for the management of hypertension from the payer perspective. METHODS: We used a decision analytic model with a 3-year time horizon based on published literature and publicly available data. The population consisted of adult patients who had a previous diagnosis of high BP (defined as office-based BP ≥ 140/90 mmHg) or were receiving antihypertensive medications. Effectiveness data were drawn from 2 published studies evaluating the effect of PPCCMs (vs usual care) on TTR for systolic BP and the impact of TTR for systolic BP on 4 cardiovascular outcomes (nonfatal myocardial infarction [MI], stroke, heart failure [HF], and cardiovascular disease [CVD] death). The model incorporated direct medical costs, including both programmatic costs (ie, direct costs for provider time) and downstream health care utilization associated with acute cardiovascular events. One-way sensitivity and threshold analyses examined model robustness. RESULTS: In base-case analyses, PPCCM hypertension management was associated with lower downstream medical expenditures (difference: -$162.86) and lower total program costs (difference: -$108.00) when compared with usual care. PPCCM was associated with lower downstream medical expenditures across all parameter ranges tested in the deterministic sensitivity analysis. For every 10,000 hypertension patients managed with PPCCM vs usual care over a 3-year time horizon, approximately 27 CVD deaths, 29 strokes, 21 nonfatal MIs, and 12 incident HF diagnoses are expected to be averted. CONCLUSIONS: This is the first study to evaluate the cost-effectiveness of PPCCM compared to usual care on TTR for systolic BP in adults with hypertension. PPCCM was less costly to administer and resulted in downstream health care savings and fewer acute cardiovascular events relative to usual care. Although further research is needed to evaluate the long-term costs and outcomes of PPCCM, payer coverage of PPCCM services may prevent future health care costs and improve patient cardiovascular outcomes. DISCLOSURES: No funding was received for the completion of this research. The authors have nothing to disclose. Study results were presented as an abstract at the AMCP 2021 Virtual, April 12-16, 2021.

Reducing acute kidney injury due to vancomycin in trauma patients.

BACKGROUND: Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring. METHODS: Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post-vancomycin administration. Those in the POST group were prospectively followed up until discharge or death. RESULTS: Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162). CONCLUSIONS: A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity. LEVEL OF EVIDENCE: Therapeutic study, level IV.