Spending on Dual Over-the-Counter and Prescription Drugs in the Medicare Part D Program.

This study compares Medicare and patient spending for dual over-the-counter and prescription drugs with their over-the-counter cash prices.

Profile of Medicaid enrollees with sickle cell disease: A high need, high cost population.

Sickle cell disease is a progressively debilitating genetic condition that affects red blood cells and can result in a variety of serious medical complications, reduced life expectancy, and diminished quality of life. Medicaid nationwide covered 66 percent of sickle cell disease hospitalizations in 2004 and 58 percent of emergency department visits for the disease between 1999 and 2007. Using Medicaid data from four states with large populations that account for more than one-third of Medicaid program enrollment, we examined the characteristics of those with sickle cell disease. We found instances of mortality rates more than nine times the age-adjusted population average (in Texas, a mortality rate for Medicaid enrollees with SCD of 1.11 percent compared to 0.12 percent overall); rates of disability-related eligibility-which is associated with long-term Medicaid enrollment-of up to 69 percent; and half or more of affected enrollees having (all-cause) hospital stays, emergency department visits, and opioid prescription fills. With gene therapies on the horizon that will spur discussions of treatment coverage, costs, and outcomes for people with sickle cell disease, it is important for relevant stakeholders to understand the affected populations.

[Investigation of Leftover Hyperphosphatemia Drugs in Hemodialysis Outpatients].

Currently, various hyperphosphatemia drugs are administered orally to hemodialysis patients in order to lower serum phosphorus levels. However, it is known that medication adherence is poor, possibly due to greater pill burden taken each time and their complicated schedules. Therefore, large amounts of unused hyperphosphatemia drugs are likely to be leftover. The increase in leftover prescribed drugs leads to the unnecessary elevation of medical care costs. To date, however, the available information on leftover hyperphosphatemia drugs in hemodialysis outpatients is limited. In this study, we performed an interview survey of medication adherence to hyperphosphatemia drugs among 60 hemodialysis outpatients and evaluated the cost of the leftover drugs. Thirty-four patients showed good adherence. On the other hand, 19 patients self-adjusted to take hyperphosphatemia drugs according to their daily diet. When assessing the serum phosphorus levels for these patients over the past year, the values often exceeded the targeted range (3.5-6.0 mg/mL). Furthermore, 35 patients kept hyperphosphatemia drugs at their home. When estimating the cost derived from leftover drugs using the bootstrap method, main distribution of drug cost was shown to be in the range of 2000 to 2500 yen. This drug cost seemed to in part reflect preparation for an emergency. A serious problem was that 14 patients had previous experience in discarding hyperphosphatemia drugs. This study suggested that more appropriate pharmaceutical care according to each patient's situation is essential in improving phosphorus control in hemodialysis outpatients and in reducing the waste of medical resources.

Association Between a National Insurer's Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending.

PURPOSE: Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending. METHODS: We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period. RESULTS: The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; P < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; P = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; P = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; P = .07) over the 6-month episode period. CONCLUSION: P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.

Characteristics, Behaviors, and Awareness of Contact Lens Wearers Purchasing Lenses Over the Internet.

OBJECTIVES: To describe the characteristics and hygiene habits of contact lens (CL) wearers who acquire CLs over the Internet, as well as their awareness of modifiable risk factors (RFs). METHODS: A web-based survey was conducted among clients of an online CL sales platform during 6 months. Demographic data, CL hygiene-related awareness, and compliance were collected and analyzed. RESULTS: The questionnaire was completed by 1,264 CL wearers: the average age was 40.8 years; most were women (71.1%), had myopia (76.4%), and wore monthly disposable CLs (63.6%). The frequency of eye examination was significantly lower among those buying the CL exclusively online (15.8% vs. 6.6%, P<0.001) and those who had begun CL use on their own (17.5% vs. 8.8%, P<0.001). Initiation to CL wear without the intervention of an eye care practitioner was more frequent in wearers with less experience. Common risk behaviors included water exposure (68.1% in swimming and 64.9% in the shower), use of the case (61.9%) and CL (65.1%) beyond the recommended replacement time, and reuse of the maintenance solution (31.9%). Ignorance of recommended hygiene increased the probability of risky behavior. CONCLUSION: There were no differences in compliance or awareness of risks between those purchasing exclusively online and other CL wearers. However, the growing frequency of self-taught initiation in CL wear among less-experienced online customers and online exclusive purchase was associated with a decrease in eye examination frequency and therefore worse compliance and increased risks. This finding underlines the importance of publicizing correct hygiene habits by all possible means so as to increase compliance.

Effects of pay-for-performance on prescription of hypertension drugs among public and private primary care providers in Sweden.

This study exploits policy reforms in Swedish primary care to examine the effect of pay-for-performance (P4P) on compliance with hypertension drug guidelines among public and private health care providers. Using provider-level outcome data for 2005-2013 from the Swedish Prescription Register, providers in regions using P4P were compared to providers in other regions in a difference-in-differences analysis. The results indicate that P4P improved guideline compliance regarding prescription of angiotensin converting enzyme inhibitors and angiotensin receptor blockers. The effect was mainly driven by private providers, suggesting that policy makers should take ownership into account when designing incentives for health care providers.

A RCT evaluating a pragmatic in-hospital service to increase the quality of discharge prescriptions.

OBJECTIVE: To improve discharge prescription quality and information transfer to improve post-hospital care with a pragmatic in-hospital service. DESIGN: A single-centre, randomized controlled trial. SETTING: Internal medicine wards in a Swiss teaching hospital. PARTICIPANTS: Adult patients discharged to their homes, 76 each in the intervention and control group. INTERVENTION: Medication reconciliation at discharge by a clinical pharmacist, a prescription check for formal flaws, interactions and missing therapy durations. Important information was annotated on the prescription. MAIN OUTCOME MEASURES: At the time of medication dispensing, community pharmacy documented their pharmaceutical interventions when filling the prescription. A Poisson regression model was used to compare the number of interventions (primary outcome). The significance of the pharmaceutical interventions was categorized by the study team. Comparative analysis was used for the significance of interventions (secondary outcome). RESULTS: The community pharmacy staff performed 183 interventions in the control group, and 169 in the intervention group. The regression model revealed a relative risk for an intervention of 0.78 (95% CI 0.62-0.99, p = 0.04) in the intervention group. The rate of clinically significant interventions was lower in the intervention group than in the control group (72 of 169 (42%) vs. 108 of 183 (59%), p < 0.01), but more economically significant interventions were performed (98, 58% vs. 80, 44%, p < 0.01). CONCLUSIONS: The pragmatic in-hospital service increased the quality of prescriptions. The intervention group had a lower risk for the need for pharmaceutical interventions, and clinically significant interventions were less frequent. Overall, our pragmatic approach showed promising results to optimize post-discharge care.

Prescription Contraceptive Sales Following the Affordable Care Act.

Objectives We examine trends in prescription contraceptive sales following the Affordable Care Act's (ACA) zero-copayment contraceptive coverage mandate in areas more likely to be affected by the provision relative to areas less likely to be affected. Methods Before the ACA, several states had their own contraceptive insurance coverage mandates. Using a national prescription claims database combined with wholesaler institutional sales activity from January 2008 through June 2014, we compare sales of the intrauterine device (IUD), implant, injectable, pill, ring, and patch in states that had a state-level insurance coverage mandate before the ACA to states that did not. Results Overall, our results imply the ACA increased sales of prescription contraceptives, with stronger effects for some methods than others. Specifically, we find the ACA increased sales of injectable contraceptives, but had no significant impact on sales of the IUD, implant, pill, or patch in states without a state-level mandate before the ACA relative to states that had a state-level mandate. We also find suggestive evidence of a reduction in sales of the ring. Conclusions for Practice Demand responses to changes in out-of-pocket expenses for contraception vary across methods. Eliminating copays could promote the use of contraceptives, but is not the only approach to increasing contraceptive utilization.

[Effects of Using the Adherence Score Sheet According to Application Timing in Improving Medication Adherence in SETSUYAKU-BAG Campaign].

Maintaining medication adherence is a critical issue in determining health outcomes in patients with chronic diseases. However, many patients do not adhere to their prescribed regimens. This study aimed to determine the effects of using adherence score sheets according to application timing in improving medication adherence among non-adherent outpatients. In community pharmacies, both patients and pharmacists evaluated medication adherence based on application timing (morning, noon, evening, and before going to bed) in 11 levels (0-10) for >4 months. A total of 58 outpatients were included in the study. The median scores among application timing at intermediate (patient 9.3, pharmacist 9.0) and final (patient 9.5, pharmacist 9.5) analyses were significantly higher than that at baseline (patient 7.6, pharmacist 7.0). At the end of the investigation, the ratio of non-adherent patients prescribed with hyperlipidemic medications was higher than those prescribed with medications for other lifestyle diseases. Approximately 80% of the patients reported improved medication adherence based on the questionnaires regarding their understanding on diseases and medications, medication awareness, and communication with pharmacists. Therefore, the utilization of an adherence score sheet according to application timing improved medication adherence of patients with chronic diseases.

[Assessing the Effects of Prescription Adjustment and Medication Non-adherence Associated with Medication Efficacy Classifications from Leftover Drugs through the SETSUYAKU-BAG Campaign].

　The increase in medical expenditure has been worsening and poses a serious social problem. Commonly, leftover drugs are retained by patients. We estimated the possible reduction in prescription rates by appropriately reusing leftover drugs, and investigated the medication efficacy classifications that render leftover drugs due to the medication non-adherence. A retrospective cross-sectional survey of prescription data was performed at community pharmacies engaged in the appropriate reuse of leftover drugs through the SETSUYAKU-BAG campaign. We evaluated the drug costs and number of drugs originally prescribed, the reduction in expenditure and numbers after the use of leftover drugs, and then calculated the prescription reduction ratio (PRR) based on the number of drugs. Factors contributing to non-adherence were analyzed by the PRR. After reviewing the prescription information of 1792 patients, the reduction rate in drug expenditure was found to be 20.1%. Purgatives, Chinese medicines, and agents for peptic ulcer had higher PRRs and belonged to the top ten medications according to the prescription efficacy classifications. Non-adherence associated with the medication efficacy classifications was assessed by analyzing 5466 formulations. Thirty percent of formulations were found to be non-adherent. According to the medication efficacy classifications, six medications including agents for hyperlipidemias, peptic ulcer, psychotropics agents, and others, were less adherent than antihypertensives. These results suggest that adjusting prescriptions by appropriately reusing leftover drugs in community pharmacies could reduce medical costs. Further considerations are necessary for improving medication adherence in Japan. Healthcare providers should monitor medication adherence more carefully, with the results identified in this study.

Breaking bread: examining the impact of policy changes in access to state-funded provisions of gluten-free foods in England.

BACKGROUND: Coeliac disease affects approximately 1% of the population and is increasingly diagnosed in the United Kingdom. A nationwide consultation in England has recommend that state-funded provisions for gluten-free (GF) food should be restricted to bread and mixes but not banned, yet financial strain has prompted regions of England to begin partially or fully ceasing access to these provisions. The impact of these policy changes on different stakeholders remains unclear. METHODS: Prescription data were collected for general practice services across England (n = 7176) to explore changes in National Health Service (NHS) expenditure on GF foods over time (2012-2017). The effects of sex, age, deprivation and rurality on GF product expenditure were estimated using a multi-level gamma regression model. Spending rate within NHS regions that had introduced a 'complete ban' or a 'complete ban with age-related exceptions' was compared to spending in the same time periods amongst NHS regions which continued to fund prescriptions for GF products. RESULTS: Annual expenditure on GF products in 2012 (before bans were introduced in any area) was £25.1 million. Higher levels of GF product expenditure were found in general practices in areas with lower levels of deprivation, higher levels of rurality and higher proportions of patients aged under 18 and over 75. Expenditure on GF food within localities that introduced a 'complete ban' or a 'complete ban with age-related exceptions' were reduced by approximately 80% within the 3 months following policy changes. If all regions had introduced a 'complete ban' policy in 2014, the NHS in England would have made an annual cost-saving of £21.1 million (equivalent to 0.24% of the total primary care medicines expenditure), assuming no negative sequelae. CONCLUSIONS: The introduction of more restrictive GF prescribing policies has been associated with 'quick wins' for NHS regions under extreme financial pressure. However, these initial savings will be largely negated if GF product policies revert to recently published national recommendations. Better evidence of the long-term impact of restricting GF prescribing on patient health, expenses and use of NHS services is needed to inform policy.

Non-prescribed sale of antibiotics for acute childhood diarrhea and upper respiratory tract infection in community pharmacies: a 2 phase mixed-methods study.

Background: Although prohibited by law and legal regulatory frameworks, non-prescribed sale of antibiotics in community medicine retail outlets (CMROs) remains a serious problem in Ethiopia. The aim of this study was to document the extent of and motivations behind non-prescribed sale of antibiotics among CMROs in Gondar town, Ethiopia. Methods: A 2 phase mixed-methods study (a simulated patient visit followed by an in-depth interview) was conducted among CMROs in Gondar town, Ethiopia. Two clinical case scenarios (acute childhood diarrhea and upper respiratory tract infection) were presented and the practice of non-prescribed sale were measured and results were reported as percentages. Pharmacy staff (pharmacists and pharmacy assistants) were interviewed to examine factors/motivations behind dispensing antibiotics without a valid prescription. Results: Out of 100 simulated visits (50 each scenarios) presented to drug retail outlets, 86 cases (86%) were provided with one or more medications. Of these, 18 (20.9%) asked about past medical and medication history and only 7 (8.1%) enquired about the patient's history of drug allergy. The most frequently dispensed medication for acute childhood diarrhoea simulation were oral rehydration fluid (ORS) with zinc (n = 16) and Metronidazole (n = 15). Among the dispensed antibiotics for upper respiratory infection simulation, the most common was Amoxicillin (n = 23) followed by Amoxicillin-clavulanic acid capsule (n = 19) and Azithromycin (n = 15). Perceived financial benefit, high expectation and/or demand of customers and competition among pharmacies were cited as the main drivers behind selling antibiotics without a prescription. Conclusions: A stringent law and policy enforcement regarding the sale of antibiotics without a valid prescription should be in place. This will ultimately help to shift the current pharmacy practices from commercial and business-based interests/practices to the provision of primary healthcare services to the community.

The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women.

OBJECTIVES: The Affordable Care Act (ACA) contraceptive coverage mandate issued in August 2012 requires most private health insurance plans to cover all U.S. Food and Drug Administration-approved contraceptive methods without cost sharing. We evaluate the impact of this policy on out-of-pocket costs and use of long-acting reversible contraceptives (LARCs) and other prescription methods through 2014. METHODS: Data from Truven Health MarketScan were used to examine out-of-pocket costs and contraceptive use patterns for all reversible prescription contraceptives before and after the implementation of the contraceptive mandate for privately insured women ages 13 to 45. Costs were estimated by combining copayment, coinsurance, and deductible payments for both contraception and insertion fees for LARCs. Contraceptive use rates were examined and multivariable logistic regression analysis of LARC insertions before and after the ACA was conducted. RESULTS: Out-of-pocket costs for all reversible contraceptives, including LARCs, decreased sharply after the ACA contraceptive mandate. The greatest proportion of women in each year was oral contraceptive users (24.3%-26.1%). Rates of new LARC insertions increased significantly after the ACA, when controlling for cohort year, age group, geographic region, and rural versus urban setting (adjusted odds ratio, 1.03; 95% confidence interval, 1.02-1.04). CONCLUSIONS: Our study adds to the current literature with the inclusion of 2014 data and confirms previous findings of a post-ACA decrease in out-of-pocket contraceptive costs. In addition, there was a small but statistically significant increase in LARC insertions after the ACA. This finding indicates the importance of reduced cost sharing for increasing use of the most effective contraceptives.