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Disparities in Health Care Utilization and Functional Limitations Among Adults With Serious Psychological Distress, 2006-2014

Weissman, Judith; Russell, David; Jay, Melanie; Beasley, Jeannette M; Malaspina, Dolores; Pegus, Cheryl
OBJECTIVE: This study compared health care access, utilization, and functional indicators among adults with and without serious psychological distress (SPD) in the years surrounding implementation of the Patient Portable and Affordable Care Act (ACA). METHODS: Adults ages 18 to 64 from the 2006-2014 National Health Interview Survey (N=207, 853) were examined on 11 access, utilization, and functional indicators: health insurance coverage (health coverage), insufficient money for medications, delay in health care (delay in care), insufficient money for health care, visiting a doctor ten or more times in the past 12 months, change in place of health care, change in place of health care due to insurance, limitations in ability to work, limitations in activities of daily living (ADLs), insufficient money for mental health care, and having seen a mental health care provider. RESULTS: Multivariate models that were adjusted for health coverage and sociodemographic characteristics indicated that compared with adults without SPD, adults with SPD had greater odds of lacking money for medications (AOR=10.0) and health care (AOR=3.1), experiencing delays in care (AOR=2.7), visiting a doctor ten or more times in the past 12 months (AOR=3.2), changing usual place of health care (AOR=1.5), changing usual place of health care because of insurance (AOR=1.5), and experiencing limitations in ADLs (AOR=3.6) and ability to work (AOR=1.8). The proportions of adults with SPD who lacked health coverage and money to buy prescriptions increased during the study period. Although this trend reversed in 2014, the proportion with SPD experiencing barriers remained above 2006 levels. CONCLUSIONS: Health care patterns among adults with SPD require greater attention.
PMID: 28412896
ISSN: 1557-9700
CID: 2532512

The value of pharmacists in health care

Patwardhan, Avinash; Duncan, Ian; Murphy, Patricia; Pegus, Cheryl
The American health care system is concerned about the rise of chronic diseases and related resource challenges. Management of chronic disease traditionally has been provided by physicians and nurses. The growth of the care management industry, in which nurses provide remote telephonic monitoring and coaching, testifies to the increasing need for care management and to the value of nonphysician clinicians. However, this model is challenged by a number of factors, including low enrollment and the growing shortage of nurses. The challenges to the traditional model are causing policy makers and payers to consider innovative models. One such model includes the pharmacist as an essential provider of care. Not only is the number of pharmacists growing, but they are playing an ever broader role in a variety of settings. This article broadly surveys the current state of pharmacist provision of care management services and highlights the increasingly proactive role played by Walgreen Co. toward this trend, using recently conducted research. Pharmacists are making a noticeable impact on and contribution to the care of chronic diseases by improving adherence to medications, a key factor in the improvement of outcomes. Literature also suggests that pharmacies are increasingly encouraging, expanding, and highlighting the role and contributions of their professional pharmacists. Although the role of the pharmacist in chronic care management is still developing, it is likely to grow in the future, given the needs of the health care system and patients.
PMID: 22313438
ISSN: 1942-7905
CID: 1293082

Place of death among patients with terminal heart failure in a continuous inotropic infusion program

Taitel, Michael; Meaux, Nita; Pegus, Cheryl; Valerian, Christopher; Kirkham, Heather
Although most patients with terminal heart failure (HF) prefer to die at home, the majority die in hospitals. To determine the impact of home inotropic support in the place of death among patients with terminal HF, this retrospective study compared the place of death in patients with terminal HF enrolled in an inotropic infusion program to place of death in a national sample of patients with HF. The rate of home death among program participants (64.5%; n = 217) was significantly higher (P < .001) than an age- and sex-adjusted rate of home death in a national sample (35.9%; n = 56 596). Patients with HF participating in home inotropic support can remain at home during the final stage of life and are less likely to die in hospitals.
PMID: 21840872
ISSN: 1049-9091
CID: 1293072

Oral chemotherapy program improves adherence and reduces medication wastage and hospital admissions

Khandelwal, Nikhil; Duncan, Ian; Ahmed, Tamim; Rubinstein, Elan; Pegus, Cheryl
Adherence, medication wastage, and reduction in hospital admissions were investigated in a retrospective test-control study design for patients enrolled in the oral chemotherapy cycle management program (CMP), a program that offers clinical support, dose monitoring, and early identification of side effects for patients on select oral chemotherapy. Patients who initiated oral chemotherapy with sorafenib, sunitinib, or erlotinib during June 2008 through December 2009 and who were enrolled in the CMP were included as a test group. Patients who initiated oral chemotherapy with these drugs using Walgreens Specialty Pharmacy during January 2007 through May 2008 and were not part of the CMP were included as control group 1, and patients from a national payor database who initiated therapy with sorafenib, sunitinib, or erlotinib during June 2008 through August 2010 were included as control group 2. Compared with control group 1, patients in the CMP group showed no significant differences with regard to their possession ratios (P > .05), but demonstrated significantly higher persistency rates (P < .05) at the end of 6 months follow-up. For patients in the CMP group who discontinued therapy, approximately 34% could have experienced reduced wastage had they been on a split medication plan. Patients who are monitored closely and able to identify serious side effects early can avoid complications leading to hospitalizations. The study showed potential savings on drug costs because of a split-fill medication plan, and savings from reduced hospitalization associated with timely identification and management of severe side effects. A clinical program, such as CMP, effectively improves adherence and reduces wastage and hospitalizations for oral chemotherapeutic agents, realizing potential cost savings to both payors and patients.
PMID: 22570292
ISSN: 1540-1405
CID: 1293092

Community pharmacy and mail order cost and utilization for 90-day maintenance medication prescriptions

Khandelwal, Nikhil; Duncan, Ian; Rubinstein, Elan; Ahmed, Tamim; Pegus, Cheryl
BACKGROUND: Pharmacy benefit management (PBM) companies promote mail order programs that typically dispense 90-day quantities of maintenance medications, marketing this feature as a key cost containment strategy to address plan sponsors' rising prescription drug expenditures. In recent years, community pharmacies have introduced 90-day programs that provide similar cost advantages, while allowing these prescriptions to be dispensed at the same pharmacies that patients frequent for 30-day quantities. OBJECTIVE: To compare utilization rates and corresponding costs associated with obtaining 90-day prescriptions at community and mail order pharmacies for payers that offer equivalent benefits in different 90-day dispensing channels. METHODS: We performed a retrospective, cross-sectional investigation using pharmacy claims and eligibility data from employer group clients of a large PBM between January 2008 and September 2010. We excluded the following client types: government, third-party administrators, schools, hospitals, 340B (federal drug pricing), employers in Puerto Rico, and miscellaneous clients for which the PBM provided billing services (e.g., the pharmacy's loyalty card program members). All employer groups in the sample offered 90-day community pharmacy and mail order dispensing and received benefits management services, such as formulary management and mail order pharmacy, from the PBM. We further limited the sample to employer groups that offered equivalent benefits for community pharmacy and mail order, defined as groups in which the mean and median copayments per claim for community and mail order pharmacy, by tier, differed by no more than 5%. Enrollees in the sample were required to have a minimum of 6 months of eligibility in each calendar year but were not required to have filled a prescription in any year. We evaluated pharmacy costs and utilization for a market basket of 14 frequently dispensed therapeutic classes of maintenance medications. The proportional share of claims for each therapeutic class in the mail order channel was used to weight the results for the community pharmacy channel. Using ordinary least squares regression models, we controlled for differences between channel users with respect to the following confounding factors: age, gender, presence or absence of each of the top 11 drug-inferred conditions (e.g., asthma/chronic obstructive pulmonary disease, cardiovascular disease), drug mix, and calendar year. We calculated estimated predicted means holding all covariates at their mean values. For both 90-day dispensing channels, we calculated number of 90-day claims per member per year (PMPY) and cost per pharmacy claim, with all claims counts adjusted to 30-day equivalents (i.e., number of 90-day claims x 3). Differences were compared using t-tests for statistical significance. RESULTS: Of 355 PBM clients prior to exclusions, 72 unique employers covering 644,071 unique members (range of approximately 100 to more than 100,000 members per employer) were included in the analysis. On an unadjusted basis, community pharmacies represented 80.8% of 90-day market basket claims (in 30-day equivalents: 3.97 claims PMPY vs. 0.95 in mail order) and 77.2% of total allowed charges. After adjustments for therapeutic group mix and patient characteristics, predicted mean pharmacy claim counts PMPY were 4.09 for community pharmacy compared with 0.85 for mail order (P less than 0.001). Predicted mean allowed charges per claim for community and mail order pharmacies did not significantly differ ($49.03 vs. $50.04, respectively, P = 0.202). CONCLUSIONS: When offered maintenance medications through community and mail order pharmacies on a benefit-equivalent basis, commercially insured employees and their dependents utilized the community pharmacy channel more frequently by a margin of more than 4 to 1 in terms of claims PMPY. Overall allowed charges per claim for community and mail order pharmacy did not significantly differ.
PMID: 22468733
ISSN: 1083-4087
CID: 1293102

Impact of an online prescription management account on medication adherence

Hou, John G; Murphy, Patricia; Tang, Andrew W; Khandelwal, Nikhil; Duncan, Ian; Pegus, Cheryl L
OBJECTIVES: To assess medication adherence rates of patients utilizing an online prescription management account compared with nonusers. STUDY DESIGN: A retrospective analysis was conducted using de-identified pharmacy claims data from a pharmacy benefit manager covering the period from April 1, 2009, to March 31, 2011. Patients who were continuously eligible throughout the study period and that had at least 1 prescription fill for any of the 8 therapeutic groups examined in the study were selected for inclusion. METHODS: Adherence was assessed by measuring the proportion of days covered (PDC). Propensity score matching was utilized to minimize differences in age, gender, chronic condition score, copay, household income, and urban locality between the users and nonusers groups. Results were reported for all therapeutic groups combined, as well as by individual therapeutic group. RESULTS: Overall, patients utilizing the online account had a significantly higher weighted average PDC (73.19% vs 61.64%, P <.0001). Users also had a higher average PDC for each individual therapeutic group, although the beta-blocker group was not statistically significant. The percentage of patients achieving an average PDC of >80% was also found to be greater in the users group across each therapeutic group and overall. CONCLUSIONS: Patients who utilized an online prescription management account had higher rates of medication adherence as compared with nonusers. Additional studies are needed to assess which specific components of the prescription management account have the biggest impact on adherence.
PMID: 22435965
ISSN: 1088-0224
CID: 1410322

Medication adherence for 90-day quantities of medication dispensed through retail and mail order pharmacies

Khandelwal, Nikhil; Duncan, Ian; Rubinstein, Elan; Ahmed, Tamim; Pegus, Cheryl; Murphy, Patricia; Kudrak, Kenneth E
OBJECTIVES: To examine relative medication adherence of patients filling 90-day supplies of maintenance medications using retail and mail order channels. It was hypothesized that adherence rates would not differ across the 2 channels. STUDY DESIGN: A cross-sectional retrospective analysis was conducted using de-identified pharmacy claims data from a large pharmacy benefit manager (PBM) database over a 2-year period (January 2008 to August 2010). Patients who were continuously eligible for at least 12 months during this time frame, with benefit plan designs that allowed filling of 90-day supplies either at retail or by mail order pharmacy, were selected. METHODS: Adherence was measured by medication possession ratio (MPR) within a 1-year period. Propensity score matching was employed to minimize differences between the Retail-90 group and Mail Order-90 group. RESULTS: Overall, patients filling 90-day prescriptions for 9 therapeutic groups (antiasthmatics and bronchodilators, antidepressants, antidiabetics, antihyperlipidemics, antihypertensives, beta blockers, calcium channel blockers, diuretics, and thyroid agents) at retail pharmacies demonstrated a propensity score-matched average MPR that was statistically higher than for patients filling prescriptions via mail order (77.0% vs 76.0%). There were no significant differences in MPR (post-matching) between 90-day retail and mail order channels for individual therapeutic groups, except for antidiabetics (80.2% vs 83.1%). CONCLUSIONS: On a propensity-matched basis, patients who fill maintenance prescriptions at retail have a slightly, but statistically significantly, higher MPR than patients who fill their prescriptions by mail
PMID: 22200059
ISSN: 1088-0224
CID: 1293122

Pharmacists as providers: targeting pneumococcal vaccinations to high risk populations

Taitel, Michael; Cohen, Ed; Duncan, Ian; Pegus, Cheryl
BACKGROUND: Older adults and persons with chronic conditions are at increased risk for pneumococcal disease. Severe pneumococcal disease represents a substantial humanistic and economic burden to society. Although pneumococcal vaccination (PPSV) can decrease risk for serious consequences, vaccination rates are suboptimal. As more people seek annual influenza vaccinations at community pharmacies, pharmacists have the ability to identify at-risk patients and provide PPSV. OBJECTIVES: The objective of this study was to evaluate the impact of pharmacists educating at-risk patients on the importance of receiving a pneumococcal vaccination. METHODS: Using de-identified claims from a large, national pharmacy chain, all patients who had received an influenza vaccination between August 1, 2010 and November 14, 2010 and who were eligible for PPSV were identified for the analysis. Based on the Advisory Committee on Immunization Practices recommendations, at-risk patients were identified as over 65 years of age or as aged 2-64 with a comorbid conditions. A benchmark medical and pharmacy claims database of commercial and Medicare health plan members was used to derive a PPSV vaccination rate typical of traditional care delivery to compare to pharmacy-based vaccination. Period incidence of PPSV was calculated and compared. RESULTS: Among the 1.3 million at-risk patients who were vaccinated by a pharmacist during the study period, 65,598 (4.88%) also received a pneumococcal vaccine. This vaccination rate was significantly higher than the benchmark rate of 2.90% (34,917/1,204,104; p<.001) representing traditional care. Patients aged 60-70 years had the highest vaccination rate (6.60%; 26,430/400,454) of any age group. CONCLUSIONS: Pharmacists were successful at identifying at-risk patients and providing additional immunization services. Concurrent immunization of PPSV with influenza vaccination by pharmacists has potential to improve PPSV coverage. These results support the expanding role of community pharmacists in the provision of wellness and prevention services.
PMID: 21864625
ISSN: 0264-410x
CID: 1293132

Impact of clinical oral chemotherapy program on wastage and hospitalizations

Khandelwal, Nikhil; Duncan, Ian; Ahmed, Tamim; Rubinstein, Elan; Pegus, Cheryl
OBJECTIVE: The oral chemotherapy cycle management program (CMP) provides clinical management support to patients receiving certain oral chemotherapies. The CMP includes a dose-monitoring (ie, split-fill) plan for early identification and management of adverse effects. If serious adverse effects are identified mid cycle, the remainder of the monthly supply is withheld, thus avoiding potential waste associated with early therapy discontinuation. This study investigated medication wastage and estimated potential cost savings for patients who were enrolled in the CMP, as compared with those who were not enrolled in the program. STUDY DESIGN: Retrospective test-control study. PATIENTS AND METHODS: Patients whose oral chemotherapy was initiated between June 2008 and February 2010 and who were enrolled in the CMP were included as the test group. Patients whose oral chemotherapy was initiated between June 2007 and May 2008 and who were not part of the CMP were included as the control group. RESULTS: Medication wastage associated with early therapy discontinuation was found to be lower in the CMP group. Approximately 34% of patients in the CMP group could have avoided medication wastage if split-fill plans had been available, potentially realizing savings of approximately $934.20 per patient. Linear probability regression models showed that the CMP group had a 2.9% probability for reduction in hospital admissions (P <.05), resulting in additional savings of approximately $440.00 per patient. Combined savings resulting from reduced wastage and hospital admissions was approximately $1374 per patient. CONCLUSION: Dose-monitoring programs such as the CMP effectively reduce wastage and serious adverse effects associated with oral chemotherapeutic agents, realizing potential cost savings for both payers and patients.
PMID: 21711067
ISSN: 1088-0224
CID: 1293142

Impact of clinical oral chemotherapy program on wastage and hospitalizations

Khandelwal, Nikhil; Duncan, Ian; Ahmed, Tamim; Rubinstein, Elan; Pegus, Cheryl
PURPOSE: The oral chemotherapy cycle management program (CMP) provides clinical management support to patients receiving certain oral chemotherapies. The CMP includes a dose-monitoring (ie, split-fill) plan for early identification and management of adverse effects. If serious adverse effects are identified mid cycle, the remainder of the monthly supply is withheld, thus avoiding potential waste associated with early therapy discontinuation. This study investigated medication wastage and estimated potential cost savings for patients who were enrolled in the CMP, as compared with those who were not enrolled in the program. STUDY DESIGN: Retrospective test-control study. PATIENTS AND METHODS: Patients whose oral chemotherapy was initiated between June 2008 and February 2010 and who were enrolled in the CMP were included as the test group. Patient whose oral chemotherapy was initiated between June 2007 and May 2008 and who were not part of the CMP were included as the control group. RESULTS: Medication wastage associated with early therapy discontinuation was found to be lower in the CMP group. Approximately 34% of patients in the CMP group could have avoided medication wastage if split-fill plans had been available, potentially realizing savings of approximately $934.20 per patient. Linear probability regression models showed that the CMP group had a 2.9% probability for reduction in hospital admissions (P < .05), resulting in additional savings of approximately $440.0 per patient. Combined savings resulting from reduced wastage and hospital admissions was approximately $1,374 per patient. CONCLUSION: Dose-monitoring programs such as the CMP effectively reduce wastage and serious adverse effects associated with oral chemotherapeutic agents, realizing potential cost savings for both payers and patients.
PMCID:3092454
PMID: 21886508
ISSN: 1554-7477
CID: 1293152