Quality of Medication Cost Conversations and Interest in Future Cost Conversations Among Older Adults.

BACKGROUND: Medication cost conversations occur less frequently than patients prefer, and it is unclear whether patients have positive experiences with them when they do occur. OBJECTIVE: To describe patients' experiences discussing their medication costs with their health care team. DESIGN: Cross-sectional survey. SETTING: Nationally representative survey fielded in the United States in 2022 (response rate = 48.5%). PATIENTS: 1020 adults over age 65. MEASUREMENTS: Primary measures were adapted from Clinician and Group Consumer Assessment of Healthcare Providers Survey visit survey v4.0 and captured patients' experiences of medication cost conversations. Additional measures captured patients' interest in future cost conversations, the type of clinicians with whom they would be comfortable discussing costs, and sociodemographic characteristics. RESULTS: Among 1020 respondents who discussed medication prices with their health care team, 39.3% were 75 or older and 78.6% were non-Hispanic White. Forty-three percent of respondents indicated that their prior medication cost conversation was not easy to understand; 3% indicated their health care team was not respectful and 26% indicated their health care team was somewhat respectful during their last conversation; 48% indicated that there was not enough time. Those reporting that their prior discussion was not easy to understand or that their clinician was not definitely respectful were less likely to be interested in future discussions. Only 6% and 10% of respondents indicated being comfortable discussing medication prices with financial counselors or social workers, respectively. Few differences in responses were observed by survey participant characteristics. LIMITATIONS: This cross-sectional survey of prior experiences may be subject to recall bias. CONCLUSION: Among older adults who engaged in prior medication cost conversations, many report that these conversations are not easy to understand and that almost one-third of clinicians were somewhat or not respectful. Efforts to increase the frequency of medication cost conversations should consider parallel interventions to ensure the discussions are effective at informing prescribing decisions and reducing cost-related medication nonadherence.

A comparison of two algorithms to identify sudden cardiac deaths in computerized databases.

PURPOSE: Two previously validated algorithms to identify sudden cardiac death using administrative data showed high positive predictive value. We evaluated the agreement between the algorithms using data from a common source population. METHODS: We conducted a cross-sectional study to assess the percent agreement between deaths identified by two sudden cardiac death algorithms using Tennessee Medicaid and death certificate data from 2007 through 2014. The source population included all deceased patients aged 18 to 64 years with Medicaid enrollment in the 6 months prior to death. To identify sudden cardiac deaths, algorithm 1 used only hospital/emergency department (ED) claims from encounters at the time of death, and algorithm 2 required death certificates and used claims data for specific exclusion criteria. RESULTS: We identified 34 107 deaths in the source population over the study period. The two algorithms identified 4372 potential sudden cardiac deaths: Algorithm 1 identified 3117 (71.3%) and algorithm 2 identified 1715 (39.2%), with 460 (10.5%) deaths identified by both algorithms. Of the deaths identified by algorithm 1, 1943 (62.3%) had an underlying cause of death not specified in algorithm 2. Of the deaths identified by algorithm 2, 1053 (61.4%) had no record of a hospital or ED encounter at the time of death, and 202 (11.8%) had a discharge diagnosis code not specified in algorithm 1. CONCLUSIONS: We found low agreement between the two algorithms for identification of sudden cardiac deaths because of differences in sudden cardiac death definitions and data sources.

Impact of a patient-centered medical home on access, quality, and cost.

CONTEXT: Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, where patients take a leading role and responsibility. OBJECTIVE: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine whether access, quality, and cost impacts differ by chronic condition status. DESIGN, SETTING, AND PATIENTS: This study conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. OUTCOME MEASURES: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. RESULTS: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care. CONCLUSIONS: Results suggest focusing first on patients with chronic conditions given the greater potential for early gains.

"Worth it if you could afford it": Patient perspectives on integrating real-time benefit tools into drug cost conversations.

BACKGROUND: Medication costs can lead to financial burdens for patients, creating barriers to effective medication use. Health care provider use of real-time benefit tools (RTBTs) may facilitate cost conversations with patients. We sought to explicate patient views on how RTBTs could be used to improve cost considerations in prescribing decisions. METHODS: We conducted focus groups to characterize patient perspectives on holding cost conversations with their physicians and to identify factors that would influence the value of RTBTs. We focused on adults aged 50+ who reported trouble paying for their prescriptions. Three groups included patients with conditions requiring high-cost treatments and one group included lower-income patients independent of their medical conditions. Focus groups were recorded, transcribed, coded, and categorized to salient themes employing inductive and deductive approaches using the Health Equity Implementation Framework. RESULTS: Focus groups were conducted from 09/2020-12/2020 including 18 participants representing cancer (n = 6), diabetes (n = 6), rheumatoid arthritis (n = 3), and lower income (n = 3). Participants were between 50-74, eight self-identified as Black, 10 as White, and eight reported earning <$50,000/year. We identified five themes regarding cost conversations (medication cost importance, past experiences with cost/cost conversations, perception of physician's role and knowledge, knowledge of existing resources, and influence on decision-making) and four RTBT-use-specific themes (advantages/disadvantages, perceived relevance, data quality concerns, and implementation considerations). CONCLUSION: Approaches that envision RTBTs as one-size-fits-all technological interventions may underestimate the complexity of incorporating price information into prescribing decisions. Nevertheless, patients highlighted the potential value of accurate, real-time information on medication costs to inform decision-making.

Cost-Related Medication Nonadherence and Desire for Medication Cost Information Among Adults Aged 65 Years and Older in the US in 2022.

Importance: Rising prescription drug costs and increasing prices for consumer goods may increase cost-related medication nonadherence. Cost-conscious prescribing can be supported by real-time benefit tools, but patient views on real-time benefit tool use and their potential benefits and harms are largely unexplored. Objective: To assess older adults' cost-related medication nonadherence, cost-coping strategies, and views on the use of real-time benefit tools in clinical practice. Design, Setting, and Participants: A weighted, nationally representative survey of adults aged 65 years and older administered via the internet and telephone from June 2022 to September 2022. Main Outcomes and Measures: Cost-related medication nonadherence; cost coping strategies; desire for cost conversations; potential benefits and harms from real-time benefit tool use. Results: Among 2005 respondents, most were female (54.7%) and partnered (59.7%); 40.4% were 75 years or older. Cost-related medication nonadherence was reported by 20.2% of participants. Some respondents used extreme forms of cost-coping, including foregoing basic needs (8.5%) or going into debt (4.8%) to afford medications. Of respondents, 89.0% reported being comfortable or neutral about being screened before a physician's visit for wanting to have medication cost conversations and 89.5% indicated a desire for their physician to use a real-time benefit tool. Respondents expressed concern if prices were inaccurate, with 49.9% of those with cost-related nonadherence and 39.3% of those without reporting they would be extremely upset if their actual medication price was more than what their physician estimated with a real-time benefit tool. If the actual price was much more than the estimated real-time benefit tool price, nearly 80% of respondents with cost-related nonadherence reported that it would affect their decision to start or keep taking a medication. Furthermore, 54.2% of those with any cost-related nonadherence and 30% of those without reported they would be moderately or extremely upset if their physicians used a medication price tool but chose not to discuss prices with them. Conclusions and Relevance: In 2022, approximately 1 in 5 older adults reported cost-related nonadherence. Real-time benefit tools may support medication cost conversations and cost-conscious prescribing, and patients are enthusiastic about their use. However, if disclosed prices are inaccurate, there is potential for harm through loss of confidence in the physician and nonadherence to prescribed medications.

Antibiotic perceptions, adherence, and disposal practices among parents of pediatric patients.

Antibiotics are frequently prescribed for children in the outpatient setting. Although sometimes necessary, antibiotic use is associated with important downstream effects including the development of antimicrobial resistance among human and environmental microorganisms. Current outpatient stewardship efforts focus on guiding appropriate antibiotic prescribing practices among providers, but little is known about parents' understanding of antibiotics and appropriate disposal of leftover antibiotics. To help bridge this gap, we conducted a qualitative study to assess parental understanding of their children's antibiotics, their adherence to antibiotic instructions, and their disposal practices. We conducted a semi-structured interview with parents of 13 children diagnosed with acute respiratory illnesses and prescribed antibiotics in an urban outpatient clinic. We found that parents had limited understanding of how antibiotics work. Although they received instructions about antibiotic use during the healthcare visit, adherence to the prescription and appropriate disposal of antibiotics was suboptimal. Limited baseline understanding of antibiotics, their prior experiences with antibiotics, perceptions about their social networks' antibiotic use, and information provided to them by healthcare providers may influence these behaviors. Our findings can inform educational efforts of outpatient stewardship programs to help optimize parental understanding of how to use and dispose of their children's antibiotics.

Physician Perspectives on Implementation of Real-Time Benefit Tools: A Qualitative Study.

OBJECTIVES: Congress and Medicare have required real-time benefit tools (RTBT) to provide patient-specific medication price information during prescribing to decrease the cost of medications. We sought physicians' perspectives on how these tools might most effectively improve their selection of low-cost medication. METHODS: We conducted 15 semi-structured interviews of physicians (6 oncologists, 1 endocrinologist, 4 rheumatologists, and 4 from internal medicine) and identified key themes across interviews during coding and analysis. RESULTS: Although physicians saw value in real-time medication price information, they were wary of the complexity of obtaining specific information and the potential for inaccuracies. Physicians described how medication price information would be used in various prescribing scenarios including from simple substitutions (different drug formulations) to more complex decisions (different drug classes). In more complex situations, physicians were concerned that price information might only be available after discussing options with the patient, which would be too late to inform decisions. Concern about adding more information to the electronic health record was common. CONCLUSION: While most physicians saw value in implementation of RTBTs, they also expressed concerns related to the accuracy of information, the availability of information at the right time in the clinical workflow, and the most effective format for information. Many concerns raised paralleled the "Five Rights of Clinical Decision Support" framework and indicate the need for additional design work to achieve benefit from RTBTs. Beyond the public policy that has supported the availability of RTBTs, substantial development will be required to ensure that information is used to improve prescribing decisions.

Building a Data Linkage Foundation for Mother-Child Pharmacoepidemiology Research.

BACKGROUND: Expanding our understanding of the effects of maternal medication exposure through research is a public health priority and will help inform both clinical and policy decision making, ultimately improving outcomes for pregnant women and their children. OBJECTIVE: Our objective was to describe a linked-data research platform that facilitates studies of pregnancy medication exposures and policy changes on maternal and child health outcomes. METHODS: Mothers receiving Medicaid benefits were probabilistically linked with newborns in the Tennessee Medicaid program (TennCare) through three distinct linkage processes. Medicaid claims data and state birth and fetal death certificate records (vital records) were used to identify and link potential mothers, deliveries, and newborn children. The linkage process started with the creation of a merged pool of potential mothers and eligible deliveries, which was linked to vital records and to children's records. In the last step, linked records from the preceding steps were combined into the final Mother-child linked records. For each data linkage step, rubrics and scoring systems for exact and partial matches and mismatches among key linkage fields were applied and used to examine the strength of the probabilistic linkages. Summary linkage yields for year 2013 are reported for illustration purposes. RESULTS: Among the 84,253 potential deliveries, 1,761,557 eligible potential mothers, and 51,400 eligible children identified in Tennessee Medicaid records in 2013, a total of 60,265 of these records were uniquely linked to vital records, including 46,172 (77%) with linked mother-child-vital records. Among the 51,400 eligible children records identified in Tennessee Medicaid for that year, 97% (50,053) had at least one link to vital records or a mother-delivery record. In linked records, the median maternal age was 24 years, and the median gestational age was 39 weeks. About 33% of pregnant women underwent cesarean birth, and 1% of births were classified as complicated deliveries. CONCLUSIONS: Supplementing existing Medicaid claims data with birth certificate records complements administrative claims information and allows for detailed assessments of pregnancy exposures and policy changes on mother and child outcomes.

State laws and policies to reduce opioid-related harm: A qualitative assessment of PDMPs and naloxone programs in ten U.S. States.

As the magnitude of the opioid epidemic grew in recent years, individual states across the United States of America enacted myriad policies to address its complications. We conducted a qualitative examination of the structure, successes, and challenges of enacted state laws and policies aimed at the opioid epidemic, with an in-depth focus on prescription drug monitoring programs (PDMPs) and naloxone access efforts. A set of 10 states (Florida, Kentucky, Massachusetts, Michigan, Missouri, New York, North Carolina, Tennessee, Washington, and West Virginia) was chosen a priori to achieve a varied sample of state policies and timing, as well as population opioid complications. Archival research was conducted to identify state-level policies aimed at the opioid epidemic and semi-structured interviews were conducted with 31 key stakeholders between March and September 2016. The most frequently mentioned key to success was an identifiable champion instrumental in leading the passage of these policies. The lack of a unified legislature and physician pushback were challenges many states faced in implementing policies. Champion-led task forces, stakeholders' personal stories garnering buy-in, ongoing education and feedback to PDMP users, and inclusive stakeholder engagement are critical aspects of passing and implementing state policies aimed at combating the opioid epidemic. Engaging all interested stakeholders and providing continuing feedback are ongoing challenges in all states. Leveraging stakeholders' personal stories of how opioids affected their lives helped propel state efforts.

Diagnostic Algorithms for Cardiovascular Death in Administrative Claims Databases: A Systematic Review.

INTRODUCTION: Valid algorithms for identification of cardiovascular (CV) deaths allow researchers to reliably assess the CV safety of medications, which is of importance to regulatory science, patient safety, and public health. OBJECTIVE: The aim was to conduct a systematic review of algorithms to identify CV death in administrative health plan claims databases. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library for English-language studies published between January 1, 2012 and October 17, 2017. We examined references in systematic reviews to identify earlier studies. Selection included any observational study using electronic health care data to evaluate the sensitivity, specificity, positive predictive value (PPV), or negative predictive value (NPV) of algorithms for CV death (sudden cardiac death [SCD], myocardial infarction [MI]-related death, or stroke-related death) among adults aged ≥ 18 years in the United States. Data were extracted by two independent reviewers, with disagreements resolved through further discussion and consensus. The Quality Assessment of Diagnostic Accuracy Studies-2 instrument was used to assess the risk of bias. RESULTS: Five studies (n = 4 on SCD, n = 1 on MI- and stroke-related death) were included after a review of 2053 citations. All studies reported algorithm PPVs, with incomplete reporting on other accuracy parameters. One study was at low risk of bias, three studies were at moderate risk of bias, and one study was at unclear risk of bias. Two studies identified community-occurring SCD: one identified events using International Classification of Disease, Ninth Revision (ICD-9) codes on death certificates and other criteria from medical claims (PPV = 86.8%) and the other identified events resulting in hospital presentation using first-listed ICD-9 codes on emergency department or inpatient medical claims (PPV = 92.3%). Two studies used death certificates alone to identify SCD (PPV = 27% and 32%, respectively). One study used medical claims to identify CV death (PPV = 36.4%), coronary heart disease mortality (PPV = 28.3%), and stroke mortality (PPV = 34.5%). CONCLUSION: Two existing algorithms based on medical claims diagnoses with or without death certificates can accurately identify SCD to support pharmacoepidemiologic studies. Developing valid algorithms identifying MI- and stroke-related death should be a research priority. PROSPERO 2017 CRD42017078745.