Assessing community pharmacy services in health professional shortage areas across Wisconsin.

BACKGROUND: Primary care health professional shortage areas (HPSAs) lack sufficient primary care providers to meet their health care needs, which contributes to worse health outcomes within underserved populations. Community pharmacies are commonly located in HPSAs and provide nondispensing services that can help address unmet health care needs. However, there is limited data on the nature, scope, and reimbursement for community pharmacy services. OBJECTIVES: Using survey data from the state of Wisconsin, this study compares the prevalence of and reimbursement for services provided by community pharmacies in primary care HPSAs and non-HPSAs and describes barriers to pharmacy service implementation. METHODS: A survey tool on pharmacy services, reimbursement, and barriers to service implementation was developed, pilot tested, and administered to every community pharmacy in Wisconsin. Data were collected via mail and online over two waves of survey administration from November 2021 to May 2022. Pearson's chi-squared and t tests were used to compare the prevalence of and reimbursement for services between HPSA and non-HPSA pharmacies. Content analysis was used to identify themes that described barriers to pharmacy service implementation. RESULTS: Responses were received from 287 of 774 eligible community pharmacies (37.1%). HPSA pharmacies were significantly more likely to be in rural areas. Regardless of pharmacy location, community pharmacies reported commonly providing a variety of services, but reimbursement for these services was considerably less frequent. The prevalence of reimbursement was <50% for two-thirds of services. Pharmacy staffing, time, and financial issues were the most commonly reported barriers to service implementation. CONCLUSIONS: Community pharmacies provide a diverse set of services to meet the health care needs of their patients, but often do so with inadequate staffing or reimbursement. Action is needed to support community pharmacies in meeting the health care needs of their communities and to ensure patient access to medications and pharmacy services.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors.

INTRODUCTION: As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage. METHODS: In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release. RESULTS: The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use. CONCLUSIONS: Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Community pharmacists and improving contraception access: Relationships between contraceptive counseling and dispensing contraceptives.

BACKGROUND: Experiences of contraceptive counseling and obtaining contraceptives vary for women of childbearing age based on education level, race, ethnicity, and health insurance. Community pharmacists are an important resource for improving access to contraceptive care in states with over-the-counter access to and pharmacist prescribing of contraceptives. OBJECTIVES: We first aimed to determine how patient education level, race, ethnicity, insurance, and patient-provider race concordance influenced the likelihood of receiving contraceptive counseling. The second aim was to determine how receiving contraceptive counseling influenced the likelihood of being dispensed contraceptives by a pharmacist. METHODS: Pearson chi-square tests and logistic regression were used to address study aims. RESULTS: Older women and those with Medicaid were less likely to receive contraceptive counseling. Race concordance had no influence on counseling. Counseling and education level were strong predictors of being dispensed contraceptives. Race, ethnicity, Medicaid, and marital status were negatively associated with being dispensed contraceptives. CONCLUSIONS: Inequities exist in access to contraceptive care for women of diverse backgrounds as well as those insured through Medicaid. State-level policy advancements and over the counter access to oral contraceptives may provide pharmacists a unique opportunity to provide contraceptive care for women without access to a primary care provider.

Characteristics of U.S. older adult medicare beneficiaries receiving the influenza vaccination at retail pharmacies.

Background: Pharmacy-provided influenza vaccination services have become more prevalent among the older adult population. However, little is known about the characteristics of older adults associated with receiving the influenza vaccination at retail pharmacies and how these associated characteristics have changed. Objective: To examine characteristics of older adults associated with use of retail pharmacy-provided influenza vaccination services and how the characteristics changed between 2009 and 2015. Methods: The study used a retrospective, cross-sectional design with data from the 2009 and 2015 Medicare Current Beneficiary Survey. Older adults aged 65 and older who completed a community questionnaire and received the influenza vaccination during the previous winter were identified. Andersen's Behavioral Model of Health Services Use was the conceptual framework for inclusion of the population characteristics. A multivariable log-binomial regression was performed to estimate the association between the population characteristics and use of pharmacy-provided vaccination service, and the relative change in associations between 2009 and 2015. Survey weights were applied in all analyses. Results: The results showed older adults who were non-Hispanic black (compared to non-Hispanic white), who did not have secondary private insurance (compared to those who had), who did not have physician office visit (compared to those who had) and who lived in non-metro area (compared to those who lived in metro area) had become more likely to use pharmacy-provided influenza vaccination services in 2015 than in 2009. Conclusions: Pharmacy-provided influenza vaccination services appear to reduce access barriers for racially and socioeconomically disadvantaged older adults. Findings could help inform not only the retail pharmacies that provide vaccination services to better outreach to potential target populations but also policy makers about the disadvantaged populations that would benefit from the vaccination services provided by retail pharmacies.

Cost-Effectiveness of a Hypothetical Gene Therapy for Alzheimer's Disease: A Markov Simulation Analysis.

Background: Alzheimer's disease is a prevalent neurodegenerative condition causing significant health and economic burden. With limited therapeutic options, clinical trials have been investigating Alzheimer's disease treatment using more novel approaches, including gene therapy. However, there is limited evidence on the cost-effectiveness of such treatments. Objectives: This research aims to explore the cost-effectiveness of a hypothetical gene therapy for patients with Alzheimer's disease at varying degrees of severity. Methods: A Markov model with a 20-year time horizon was constructed for simulated cohorts with mild cognitive impairment due to Alzheimer's disease, assigned to receive either standard of care or a one-time gene therapy administration. Varying costs of care due to disease severity and treatment efficacy were utilized to determine the effect of those variables at different willingness-to-pay thresholds. Results: Under the initial assumption that the hypothetical gene therapy grants a 30% risk reduction in disease progression and entry into institutional care, the maximum cost-effective price for gene therapy is $141,126 per treatment using the threshold of $150,000 per quality-adjusted life year (QALY). By increasing the treatment effectiveness to 50%, cost-effective price nearly doubled at each willingness-to-pay threshold (e.g., $260,902 at the $150,000/QALY threshold). Conclusion: Despite being cost-effective at a very high price, the hypothetical gene therapy for AD would still need to be priced considerably lower than other approved gene therapies on the market. Thus, a comprehensive pharmacoeconomic assessment remains critical in pricing innovative therapy and determining coverage for patients in need.

The Association of Caregiver Characteristics and Caregivers' Perceived Difficulty in Medication Management Tasks.

Background: Medication management tasks are commonly performed by family caregivers caring for patients with dementia, but caregivers also reported difficulties in performing these tasks. Objectives: Using the 2017 National Study of Caregiving (NSOC) and the 2017 National Health and Aging Trends Study (NHATS), this study examined the association between caregiver characteristics and caregiver difficulty in performing medication management tasks (e.g., ordering medications, keeping track of medications, giving shots). Methods: The main independent variable was the number of medication management tasks performed by the caregivers. The dependent variable was difficulty in performing medication management tasks. Other variables of interest included caregiver age, sex, education, co-residence with the care recipient, and use of support services. This study used the Pearlin's Stress and Coping Model to select other control variables from hundreds of variables contained in the NSOC. A lasso logistic regression model was used to account for the large amount of other control variables. Results: Caregiver difficulty was found mainly in keeping track of medications or giving shots (42.4%). More medication management tasks were significantly related to caregiver difficulty [OR=2.71; 95% CI (1.84 - 3.99)]. A significant association linking support service use with task difficulty was also observed [OR=1.82; 95% CI (1.06 - 3.13)], which warrants additional research. Conclusions: Caregiver difficulty was found mainly in keeping track of medications or giving shots. More medication management tasks were significantly related to caregiver difficulty. Since patients with dementia are often on multiple medications, it is crucial to ensure medication management is done correctly to avoid adverse health consequences.

Addressing the opioid epidemic through community pharmacy engagement: Study protocol for a randomized controlled trial.

BACKGROUND: Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed. OBJECTIVE: To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates. METHODS: A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates. CONCLUSION: Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

Financial burden and medication adherence among near-poor older adults in a pharmaceutical assistance program.

BACKGROUND: With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments. OBJECTIVES: To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members. METHODS: SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence. RESULTS: From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001). CONCLUSIONS: The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.

Five-year impact of Medicare Part D coverage gap reform on drug expenditures and utilization.

OBJECTIVE: To estimate the impact of the Medicare Part D coverage gap reform under the Affordable Care Act (ACA) on the utilization of and expenditures for prescription drugs within the first five years of the policy's implementation. DATA SOURCES: 2008-2015 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: We used a difference-in-differences approach to estimate the year-by-year changes in prescription drug use and expenditures before (2006-2010) and after (2011-2015) the ACA's Part D coverage gap reform between Part D beneficiaries not receiving the Low-Income Subsidy (LIS) and those receiving the LIS. DATA COLLECTION: The study sample included Part D beneficiaries (a) aged 65 years or older; (b) not disabled or having end-stage renal disease; (c) continuously enrolled in a Part D plan (d) having at least one prescription fill in a given year. Survey-reported and administrative Part D events data in the MCBS were used for the analyses. PRINCIPAL FINDINGS: After the ACA reform, annual out-of-pocket drug spending significantly decreased by $88 (P < .01) among non-LIS beneficiaries compared to LIS beneficiaries, with growing decreases over time (average decreases of $41 in 2011, $49 in 2012, $105 in 2013, and $135 in 2015, P < .01 or <.05). Changes in out-of-pocket costs were largely driven by significant decreases among brand-name drugs (overall decrease of $106, P < .01). Despite significantly reduced out-of-pocket spending, there were no significant changes in the overall number of 30-day drug fills and total drug spending; however, changes in the use of brand-name and generic drugs were seen after the ACA (increase of 1.9 fills for brand-name drugs and decrease of 2.3 fills for generic drug in 2015, P < .05). CONCLUSIONS: The ACA coverage gap reform has helped to reduce the out-of-pocket drug cost burden for beneficiaries, although it had no noticeable impact on drug use or total drug spending.

High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017.

OBJECTIVE: We examined the magnitude of and trends in the burden of out-of-pocket (OOP) costs among Medicare beneficiaries age 65 years or older with diabetes overall, by income level, by race/ethnicity, and compared with beneficiaries without diabetes. RESEARCH DESIGN AND METHODS: Using data from the 1999-2017 Medicare Current Beneficiary Survey, we estimated average annual per capita OOP costs and percentage of beneficiaries experiencing high OOP burden, defined as OOP costs >10% or >20% of household income. We used joinpoint regression to examine the trends and generalized linear model and logistic regression for comparisons between beneficiaries with and without diabetes. Cost and income estimates were adjusted to 2017 USD. RESULTS: Total OOP costs were $3,609-$5,283, with significant increases until 2005 followed by a leveling off. The prevalence of high OOP burden was 57%-72% at the 10% income threshold and 29%-41% at the 20% threshold, with significant increasing trends until 2003 followed by decreases. Total OOP costs were the highest in the ≥75% income quartile, whereas prevalence of high OOP burden was highest in the <25% and 25-50% income quartiles. Non-Hispanic Whites had the highest OOP costs and prevalence of high OOP burden. Beneficiaries with diabetes had significantly higher OOP costs ($498, P < 0.01) and were more likely to have high OOP burden than those without diabetes (odds ratios 1.32 and 1.25 at >10% and >20% thresholds, respectively, P < 0.01). CONCLUSIONS: Over the past two decades, Medicare beneficiaries age 65 years or older with diabetes have faced substantial OOP burden, with large income-related disparities.

Influenza vaccination rates and location for receiving the influenza vaccination among older adult Medicare beneficiaries.

OBJECTIVES: The objectives of this study were to (1) assess the trends in older adult influenza vaccination rates and (2) locations at which U.S. older adults received influenza vaccinations for the 2008-2009 to 2017-2018 influenza seasons, and (3) compare the estimates of influenza vaccination rates and locations with the estimates from other sources reported previously. METHODS: Data from the 2009 to 2017 Medicare Current Beneficiary Survey (MCBS) were used in this analysis. The weighted sample included an average of approximately 37 million community-dwelling older Medicare beneficiaries who completed questionnaires per year. The estimates for older adult influenza vaccination rates and the locations that they used to receive the influenza vaccination were weighted and reported for the 2008-2009 to 2017-2018 influenza seasons. RESULTS: The self-reported older adult influenza vaccination rates between 2008-09 and 2017-2018 ranged from 69.6% (24.6 million) to 75.0% (31.3 million). Across the study period, the percentage of older adults receiving the influenza vaccination at a physician office and clinic declined by 10.4%. The decline was more than offset by an increase in older adult influenza vaccination receipt at a community pharmacy, which substantially increased from 16.6% (4.1 million) in 2008-2009 to 34.8% (10.9 million) in 2014-2015. When compared with the estimates from other sources, the absolute value of the MCBS estimates corresponds with National Health Interview Survey estimates. The older adult influenza vaccination rate increased slightly between the 2008-2009 and 2017-2018 influenza seasons but is still below the 90% benchmark. CONCLUSION: Community pharmacies-increasingly important access points for the influenza vaccination for older adults-likely contributed to the growth in the rate of older adults vaccinated with influenza vaccines.

Illustrating access to community pharmacies in Wisconsin.

OBJECTIVES: Community pharmacists also play a vital public health role in increasing access to health care services and information during times of public health crisis. To examine access to community pharmacies in Wisconsin and the relationship between pharmacy locations and primary care health professional shortage areas (HPSAs). METHODS: A list of licensed pharmacies in Wisconsin was screened to identify community pharmacies. Rural-urban commuting area codes were used to classify the rurality of pharmacy locations. Descriptive measures and pharmacy location maps were used to assess access to community pharmacies in the state as well as the relationship between pharmacy locations and primary care HPSAs. Spatial analysis was conducted to estimate the percentage of the population that lives within 10-, 20-, and 30-minute drive times of each community pharmacy. RESULTS: Of the 837 community pharmacies in Wisconsin, 73 (68.5%) were located in metropolitan areas, 95 (11.4%) in micropolitan areas, 112 (13.4%) in small towns, and 57 (6.8%) in rural areas. A total of 265 (31.7%) community pharmacies were located in a primary care HPSA. The drive-time analysis found that 99.7% of the population lives within 30 minutes of a pharmacy, 98.7% within 20 minutes of a pharmacy, and 89.3% within 10 minutes of a pharmacy. CONCLUSIONS: Nearly the entire Wisconsin population has convenient access to community pharmacies. Community pharmacies are ideally located in underserved areas with shortages of other health professionals, which may provide an opportunity for pharmacists to take on additional clinical roles to support health care providers and facilities in these areas.

Development and validation of a theory-based instrument to predict community pharmacists' intention to provide pharmaceutical care services.

BACKGROUND: Predicting pharmacists' intention to provide Pharmaceutical Care (PC) and identifying modifiable factors associated with their intention can aid in the design and tailoring of behavior-based interventions to promote the adoption of PC as a standard of pharmacy practice. There is a need for valid and reliable instruments that are theoretically grounded to measure these factors. OBJECTIVE: To develop and test the psychometric properties of the "Pharmaceutical Care Intention (PCI) scale" to identify socio-cognitive factors associated with community pharmacists' intention to provide PC services to patients with chronic conditions. METHODS: A self-administered questionnaire was developed in English and translated into Arabic, guided by constructs derived from a modified Theory of Planned Behavior (TPB) framework and a thorough review of the PC literature. The questionnaire was reviewed for face and content validity, pilot tested, and then administered to a sample of community pharmacists in Alexandria, Egypt. Exploratory factor analysis (EFA) was employed to identify and refine the underlying dimensional structure of the PCI scale and test for its convergent and discriminant validity. Reliability was assessed by computing Cronbach's α. RESULTS: Out of the 109 approached pharmacists, 97 usable responses were analyzed (response rate = 89%). EFA resulted in a 23-item, 6-factor solution explaining 52.14% of the variance in responses and providing evidence for convergent and discriminant validity. The resulting factors aligned with the modified TPB constructs: intention (α = 0.74), attitude (α = 0.89), subjective norm (α = 0.58), perceived behavioral control to identify (α = 0.66) and intervene (α = 0.82) to address drug-related problems, and perceived moral obligation (α = 0.72). Cronbach's α of the pooled items of the PCI scale was 0.77. CONCLUSION: The PCI scale is a parsimonious, theory-driven instrument with acceptable construct validity and reliability to examine factors associated with community pharmacists' intention to provide PC.

Medicaid prescription limits and their implications for naloxone accessibility.

BACKGROUND: Expanding access to and utilization of naloxone is a vitally important harm reduction strategy for preventing opioid overdose deaths, particularly in vulnerable populations like Medicaid beneficiaries. The objective of this study was to characterize the landscape of monthly prescription fill limit policies in Medicaid programs and their potential implications for expanding naloxone use for opioid overdose harm reduction. METHODS: A cross-sectional, multi-modal online and telephonic data collection strategy was used to identify and describe the presence and characteristics of monthly prescription fill limit policies across state Medicaid programs. Contextual characteristics were described regarding each state's Medicaid enrollment, opioid prescribing rates, and overdose death rates. Data collection and analysis occurred between February and May 2020. RESULTS: Medicaid-covered naloxone fills are currently subject to monthly prescription fill limit policies in 10 state Medicaid programs, which cover 20 % of the Medicaid population nationwide. Seven of these programs are located in states ranking in the top 10 highest per-capita opioid prescribing rates in the country. However, 8 of these programs are located in states with opioid overdose death rates below the national average. CONCLUSIONS: Medicaid beneficiaries at high risk of opioid overdose living in states with monthly prescription fill limits may experience significant barriers to obtaining naloxone. Exempting naloxone from Medicaid prescription limit restrictions may help spur broader adoption of naloxone for opioid overdose mortality prevention, especially in states with high opioid prescribing rates. Achieving unfettered naloxone coverage in Medicaid is critical as opioid overdoses and Medicaid enrollment increase amid the COVID-19 pandemic.

Operationalizing occupational fatigue in pharmacists: An exploratory factor analysis.

BACKGROUND: The Quadruple Aim recognizes that caring for the healthcare employee is necessary to optimize patient outcomes and health system performance. Although previous research has assessed pharmacists' workload, this study is the first to describe pharmacist occupational fatigue-a characteristic of excessive workload that inhibits workers' abilities to function at normal capacity. OBJECTIVE: (s): The purpose of this study was to describe occupational fatigue in pharmacists using exploratory factor analysis (EFA)-assessing whether dimensional structures used to describe occupational fatigue in other health professions fit pharmacist perceptions. METHODS: A model was created to conceptualize two "fatigue" domains found in the literature-physical fatigue (ex. Physical discomfort) and mental fatigue (ex. trouble thinking clearly). These domains were operationalized and used to create a survey that was distributed to licensed pharmacists at a conference. An EFA was conducted to identify the key domains underlying pharmacist perceptions of fatigue. RESULTS: A total of 283 surveys were distributed, and 115 were returned and useable. Respondents were primarily white, female, and worked 9.5 h-per-day on average. The EFA suggested a statistically significant two-factor model (Χ2 9.73, p = 0.28), which included physical fatigue (α = 0.87) and mental fatigue (α = 0.82) dimensions. CONCLUSIONS: The EFA yielded a structure similar to what was anticipated from the literature. While working, pharmacists may not be aware of fatigue related short-cuts or lapses that pose risks to patient safety. This study is just the first step in promoting systematic interventions to prevent or cope with fatigue and prevent the patient, pharmacist, and institutional outcomes.

Part D coverage gap reform: trends in drug use and expenditures.

OBJECTIVES: This study analyzed annual trends in the distribution of beneficiaries entering each benefit phase and the utilization of and expenditures for prescription drugs among Medicare Part D beneficiaries from 2008 to 2015. STUDY DESIGN: Retrospective, repeated cross-sectional analysis using Medicare Current Beneficiary Survey data. METHODS: The study population included elderly Part D beneficiaries without a low-income subsidy, with continuous enrollment in a Part D plan, and with at least 1 prescription fill for a given year. We assessed annual trends for 3 outcomes: (1) proportion of beneficiaries entering each benefit phase and the number of days taken to enter these phases, (2) number of 30-day prescription drug fills, and (3) total and out-of-pocket spending on prescription drugs. RESULTS: The proportion of beneficiaries reaching the catastrophic coverage phase increased after the Affordable Care Act (ACA), and they reached the threshold earlier in the year. The overall number of 30-day drug fills increased over the study period, although no statistically significant changes in utilization were seen among those reaching the catastrophic coverage phase. Total drug spending steadily increased over time, particularly after the ACA, with the largest increase seen in those reaching the catastrophic threshold; however, out-of-pocket spending significantly decreased. CONCLUSIONS: Although this study provides support for reductions in financial barriers to prescription drugs under the ACA, substantial increases in both total drug spending and the proportion of high-cost beneficiaries in the Part D program indicate a growing burden of Part D spending on the Medicare program, which is expected to continue to grow in the future.

Does evidence matter? Comparative effectiveness research and prescribing of Type 2 diabetes mellitus drugs.

Aim: Comparative effectiveness research (CER) can help ascertain value of new drugs; however, limited research assesses the translation of CER into clinical practice. The objective of this study was to analyze the association between CER evidence and prescribing trends within two markets of Type 2 diabetes mellitus. Methods: A retrospective analysis to determine the prescribing trends from 2006 to 2016 and an electronic literature search to identify CER comparing different drugs was conducted. Results: In glucagon-like peptide-1 (GLP-1) agonists market, CER showed superiority of Liraglutide. Prescribing of Exenatide twice daily dropped by 50% points as Liraglutide entered the market. In dipeptidyl peptidase-4 (DPP4) inhibitors market, CER did not suggest conclusive superiority. Nevertheless, Sitagliptin, the first entrant, continued to dominate throughout. Conclusion: CER evidence appeared to be associated with prescribing trends in GLP-1 agonists market; however, no associations were found in DPP4 inhibitors market. The translation of evidence into practice can be limited by the availability of superiority trials and timing of their availability.

Factors Associated with County-Level Variation in the Prescription of Statins.

BACKGROUND: The American College of Cardiology/American Heart Association recommends statins for adults aged 40-75 years with a cardiovascular disease risk factor and a 10-year risk of cardiovascular events of 7.5%-19.9%. OBJECTIVE: To examine the association of county-level social determinant measures of health and composition of health services with use of statin prescriptions under Medicare Part D. METHODS: We used 2013 Medicare Part D prescriber county-level data to construct 2 measures of statin use: (1) statin beneficiaries ÷ total beneficiaries (prevalence [ßPR]) and (2) statin days supplied ÷ (total beneficiaries × 365; adequacy of supply [ßAS]). We used multivariable regression to estimate the association of each measure with county-level demographics and health service measures. RESULTS: A 1 standard deviation (SD) increase in the proportion of African Americans living in a county is associated with a 0.096 SD decrease in adequacy of supply (ßAS = -0.096; 95% CI = -0.14 to -0.06). The proportion of county residents aged 65+ years who are female was associated with higher prevalence and adequacy of supply (ßPR = 0.06; 95% CI = 0.02 to 0.11; ßAS = 0.09; 95% CI = 0.05 to 0.14). Counties with higher proportions of Medicare Part D prescription expenditures receiving low-income subsidies had lower adequacy of supply (ßAS = -0.28; 95% CI = -0.32 to -0.23). Counties with a higher proportion of Medicare Part D prescribers who are nurse practitioners was associated with lower prevalence and adequacy of supply (ßPR = -0.39; 95% CI = -0.44 to -0.35; ßAS = -0.42; 95% CI = -0.47 to -0.37). CONCLUSIONS: Race and ethnicity, income, and distribution of provider types were significantly associated with county-level variation in statin use, despite being unlikely to measure differences in actual medical need. Such variation more likely reflects predisposing and enabling factors potentially affected by social, economic, and public health policy. Tracking variation in county-level statin use associated with these factors could help policymakers assess progress in reducing health care disparities and better target program resources. DISCLOSURES: No funding was received for this work. Karpinski reports employment by Aetna, Anthem, and Ingenio-Rx. Vanness reports unrelated consulting fees from CHEORS, Evidera, BMS, Novartis, and Merck. Look has nothing to disclose.

The Effect of Reduced Drug Copayments on Adherence to Oral Diabetes Medications Among Childless Adults in Wisconsin Medicaid.

BACKGROUND: Medication adherence is an indicator of the quality of drug use, which is associated with better health outcomes and reduced health care expenditures. Drug cost sharing can be a barrier to adherence, especially for low-income individuals with chronic conditions. Most of the existing studies in a Medicaid population have evaluated the effects of increasing drug copayments, but few studies have evaluated the effects of reducing drug copayments on medication adherence. Medicaid coverage for low-income childless adults in Wisconsin was expanded on April 1, 2014, which included reductions in drug copayments and monthly caps on out-of-pocket spending. OBJECTIVE: To evaluate changes in adherence to oral diabetes medications using proportion of days covered (PDC) among Medicaid childless adults with type 2 diabetes after the 2014 Medicaid drug copayment reduction. METHODS: A difference-in-differences design was used to compare the changes in medication adherence between childless adults (treatment group) and parents/caretakers (control group). Wisconsin Medicaid's administrative enrollment records, pharmacy claims, and medical claims data were analyzed. Medication adherence was evaluated for 4 commonly used oral diabetes drug classes (i.e., biguanides, sulfonylureas, dipeptidyl peptidase-IV inhibitors, and thiazolidinediones) by adapting the medication adherence quality measures endorsed by the Pharmacy Quality Alliance. The PDC for all diabetes drugs was calculated among patients who filled ≥ 2 prescriptions for any of the 4 drug classes. PDC for each drug class was also measured among patients who had ≥ 2 drug fills for each drug class. The proportion of adherent patients was evaluated using a threshold of PDC ≥ 0.80. RESULTS: Average PDC for all diabetes drugs was 0.87 in the childless adults at baseline and significantly increased by 0.02 (P = 0.025) relative to the parents/caretakers after the copayment reduction. The baseline proportion of adherent patients (PDC ≥ 0.80) among the childless adults was 76% and significantly increased by 6.2 percentage points (P = 0.003) relative to the control group. The odds of adherence to oral antidiabetic drugs increased by 47%, resulting in the proportion of adherent patients in the childless adults group reaching almost 80% after the coverage expansion. In the per class analyses, a significant effect was found for biguanides; the proportion of adherent patients increased by 5.5 percentage points in childless adults compared with the control group (P = 0.022). CONCLUSIONS: This program evaluation found that a reduction of drug copayments in Wisconsin Medicaid improved the quality of medication use by increasing adherence to oral antidiabetic drugs among childless adults. DISCLOSURES: This study was conducted as part of a larger study funded by the Wisconsin Department of Health Services. The authors are solely responsible for the content of this study. The authors report an evaluation contract with the Wisconsin Department of Health Services, unrelated to this study. An earlier version of this paper was presented at the AcademyHealth Annual Research Meeting; June 23-24, 2018; Seattle, WA.

Health Care Expenditure Burden of Cancer Care in the United States.

Using nationwide data, this study estimated and compared annual health care expenditures per person between noncancer and cancer patients, and among patients with the 4 most common cancers. Two-part models were used to estimate mean expenditures for each group by source of payment and by service type. We found that cancer patients had nearly 4 times higher mean expenditures per person ($16 346) than those without cancer ($4484). These differences were larger among individuals aged 18 to 64 years than those ≥65 years. Medicare was the largest source of payment for cancer patients, especially among those ≥65 years. Among the 4 most common cancers, the most costly cancer was lung cancer. Ambulatory care visits accounted for the majority of health care expenditures for those with breast cancer, while for those with other cancers, inpatient services also contributed to a significant portion of expenditures especially among younger patients. This study demonstrates that cancer patients experience a substantially higher health care expenditure burden than noncancer patients, with lung cancer patients having the highest expenditures. Expenditure estimates varied by age group, source of payment, and service type, highlighting the need for comprehensive policies and programs to reduce the costs of cancer care.