Kevin A. Look

Multiple pharmacy use and types of pharmacies used to obtain prescriptions

OBJECTIVES To evaluate trends and patterns in the prevalence of multiple pharmacy use (MPU) and to describe the number and types of pharmacies used by multiple pharmacy users from 2003 to 2009. DESIGN Retrospective, cross-sectional, descriptive study. SETTING United States from 2003 to 2009. PARTICIPANTS 89,941 responses to the Medical Expenditure Panel Survey over 7 years. INTERVENTION Analysis of respondent pharmacy use behaviors. MAIN OUTCOME MEASURES Annual use of more than one pharmacy and number and types of pharmacies used. RESULTS MPU among patients using medications increased significantly during the study period (from 36.4% [95% CI 35.2-37.6] in 2003 to 43.2% [41.9-44.4] in 2009)-a relative increase of 18.7% ( P = 0.01). Multiple pharmacy users used between 2 and 17 different pharmacies per year to obtain prescription medications. Although approximately 70% of multiple pharmacy users used only two pharmacies, the proportion using three or more pharmacies increased from 24.1% (22.5-25.7) in 2003 to 29.1% (27.4-30.8) in 2009. Mail service pharmacy use had the largest relative increase among multiple pharmacy users during the study period (27.2%), and MPU was nearly twice as high (75%) among mail service users compared with non-mail service users. CONCLUSION MPU is common on a national level and has increased greatly in recent years. Patient use of pharmacies that have the potential to share medication information electronically is low among multiple pharmacy users, suggesting increased workload for pharmacists and potential medication safety concerns. This has important implications for pharmacists, as it potentially impedes their ability to maintain accurate medication profiles for patients.

Medication management activities performed by informal caregivers of older adults

Background: Medication management is commonly performed by informal caregivers, yet they are often unprepared and ill‐equipped to manage complex medication regimens for their older adult care recipients. In order to develop interventions that will enhance the caregivers ability to safely and confidently manage medications, it is critical to first understand caregiver challenges and unmet needs related to medication management. Objectives: To explore how informal caregivers manage medications for their older adult care recipients by identifying the activities involved in medication management and the tools or strategies used to facilitate these activities. Methods: Four focus groups with caregivers of older adults were conducted with 5–9 caregivers per group. Participants were asked to describe the medication management activities performed and the tools or strategies used to facilitate these activities. Focus groups were recorded, transcribed verbatim, and analyzed for themes using an inductive approach. Results: Caregivers were commonly involved in 2 types of activities: direct activities requiring physical handling of medications such as obtaining medications, preparing pill boxes, and assisting with medication administration; and indirect activities that were more complex and required more of a cognitive effort by the caregiver, such as organizing and tracking medications, gathering information, and making treatment decisions. They utilized a variety of tools and strategies to support these medication management activities; however, these approaches often needed to be modified or personalized to meet the specific needs of their caregiving situation. Conclusions: Informal caregivers play a vital role in ensuring safe and appropriate medication use by older adults. Medication management is complex and involves many activities that are supported through the use of a variety of tools and strategies that have been adapted and individualized to each specific caregiving scenario. Caregivers should be an important component of interventions that aim to improve medication use among older adults. HIGHLIGHTSCare recipient health status determined caregiver involvement with medications.Monitoring activities were more complex and required more cognitive effort.Some caregiver take on provider‐like roles to adjust medication regimens.Tools and strategies often need to be modified to meet caregiver needs.Caregivers experienced difficulties even in relatively basic caregiving situations.

Effects of the Affordable Care Act's Dependent Coverage Mandate on Private Health Insurance Coverage in Urban and Rural Areas.

Purpose To evaluate the impact of the Affordable Care Acts (ACA) dependent coverage mandate on insurance coverage among young adults in metropolitan and nonmetropolitan areas. Methods A cross-sectional analysis was conducted using data from 2006-2009 and 2011 waves of the Medical Expenditure Panel Survey. A difference-in-difference analysis was used to compare changes in full-year private health insurance coverage among young adults aged 19-25 years with an older cohort aged 27-34 years. Separate regressions were estimated for individuals in metropolitan and nonmetropolitan areas and were tested for a differential impact by area of residence. Findings Full-year private health insurance coverage significantly increased by 9.2 percentage points for young adults compared to the older cohort after the ACA mandate (P = .00). When stratifying the regression model by residence area, insurance coverage among young adults significantly increased by 9.0 percentage points in metropolitan areas (P = .00) and 10.1 percentage points in nonmetropolitan areas (P = .03). These changes were not significantly different from each other (P = .82), which suggests the ACA mandates effects were not statistically different by area of residence. Conclusions Although young adults in metropolitan and nonmetropolitan areas experienced increased access to private health insurance following the ACAs dependent coverage mandate, it did not appear to directly impact rural-urban disparities in health insurance coverage. Despite residents in both areas gaining insurance coverage, over one-third of young adults still lacked access to full-year health insurance coverage.PURPOSE To evaluate the impact of the Affordable Care Acts (ACA) dependent coverage mandate on insurance coverage among young adults in metropolitan and nonmetropolitan areas. METHODS A cross-sectional analysis was conducted using data from 2006-2009 and 2011 waves of the Medical Expenditure Panel Survey. A difference-in-difference analysis was used to compare changes in full-year private health insurance coverage among young adults aged 19-25 years with an older cohort aged 27-34 years. Separate regressions were estimated for individuals in metropolitan and nonmetropolitan areas and were tested for a differential impact by area of residence. FINDINGS Full-year private health insurance coverage significantly increased by 9.2 percentage points for young adults compared to the older cohort after the ACA mandate (P = .00). When stratifying the regression model by residence area, insurance coverage among young adults significantly increased by 9.0 percentage points in metropolitan areas (P = .00) and 10.1 percentage points in nonmetropolitan areas (P = .03). These changes were not significantly different from each other (P = .82), which suggests the ACA mandates effects were not statistically different by area of residence. CONCLUSIONS Although young adults in metropolitan and nonmetropolitan areas experienced increased access to private health insurance following the ACAs dependent coverage mandate, it did not appear to directly impact rural-urban disparities in health insurance coverage. Despite residents in both areas gaining insurance coverage, over one-third of young adults still lacked access to full-year health insurance coverage.

Economic impact of pharmacist-reimbursed drug therapy modification

OBJECTIVE To determine (1) the frequency of the different types of drug therapy modification claims paid by a pharmacy benefits manager (PBM), (2) PBM cost savings and return on investment (ROI), and (3) patient savings from pharmacist-reimbursed drug therapy modifications. DESIGN Cross-sectional, retrospective, descriptive study. SETTING Midwest United States in 2006. PATIENTS Not applicable; 767 paid therapeutic interchange service claims from the PBM database were analyzed. INTERVENTION Descriptive statistics for PBM costs and cost savings to the PBM and to patients were calculated using all prescription fills. MAIN OUTCOME MEASURE ROI calculated by dividing net savings across all fills by net costs. RESULTS Claims were paid to pharmacists for drug therapy modifications to allow tablet splitting, drug therapy changes, and switching noncovered drugs. Tablet splitting provided the largest cost savings to the PBM, accounting for slightly more than one-third of the claims and representing more than one-half of the prescription fills. Switching drugs not covered provided the largest cost savings to patients. Overall, the PBM saved a mean of

Patient characteristics associated with multiple pharmacy use in the U.S. population: Findings from the Medical Expenditure Panel Survey

20.31 per prescription fill, and patients saved

Relationship Between Objective Financial Burden and the Health-Related Quality of Life and Mental Health of Patients With Cancer

14.76 per prescription fill. Mean overall ROI to the PBM was 3.55. CONCLUSION Payment for pharmacist interventions can be an economic benefit for both patients and third-party payers. The cost savings for payers likely will dictate the endorsement of pharmacist-reimbursed programs and economic incentives offered to pharmacists and pharmacies.

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis

BACKGROUND Multiple pharmacy use (MPU) is an important safety and quality issue, as it results in fragmented patient care. However, few studies have examined patient characteristics predicting the use of multiple pharmacies, and the findings have been inconsistent. OBJECTIVES To identify patient characteristics associated with MPU using national data. METHODS Data were obtained from the 2011 U.S. Medical Expenditure Panel Survey. The dependent variable was MPU, or the use of more than one pharmacy. The Andersen Behavioral Model of Health Service Use was used to guide the selection of independent variables, which were categorized as predisposing, enabling, and medical need related characteristics. Multivariable logistic regression analysis was conducted to identify the relationships between predisposing, enabling, and need variables and MPU in a hierarchical fashion. Point estimates were weighted to the U.S. non-institutionalized population, and to adjust standard errors to account for the complex survey design. RESULTS MPU was common, with a national prevalence of 41.3%. Individuals aged 40-64 and adults 65 and older were significantly less likely to use multiple pharmacies as patients aged 18-39 years (40-64 years OR: 0.67, CI: 0.58-0.77; ≥65 years OR: 0.49, CI: 0.41-0.58). Females were significantly more likely to use multiple pharmacies than males (OR: 1.16, CI: 1.05-1.29). Individuals lacking health insurance were more likely to use multiple pharmacies as individuals with private health insurance (OR: 1.42, CI: 1.16-1.73); in contrast, individuals having drug insurance were more likely to use multiple pharmacies (OR: 1.25, CI: 1.06-1.47) relative to those without drug insurance. Any mail order use was the strongest predictor of MPU (OR: 6.94, CI: 5.90-8.18). CONCLUSIONS Pharmacists and other health care providers need to be aware that their patients may be using multiple pharmacies, especially younger patients, those lacking access to health insurance, or those using mail order pharmacies. The findings from this study can be used to identify patients that may need additional monitoring to ensure safe and appropriate drug therapy, and has important implications as health care continues to shift toward performance-based reimbursement and quality ratings.

Community pharmacies as access points for addiction treatment

PURPOSE The high and increasing costs of cancer care can lead to financial burden for patients and their families. However, no study has specifically examined the association between objective measures of financial burden and the health-related quality of life (HRQOL) and psychological health of patients with cancer. METHODS Data on patients with cancer were obtained from the 2010 to 2014 Medical Expenditure Panel Survey. High financial burden was defined as a ratio of annual family out-of-pocket health care expenditures to family income exceeding either 10% or 20%. Multivariable linear regressions were used to estimate the relationship between high financial burden and patient HRQOL, nonspecific psychological distress, and depressed mood. RESULTS Of 6,799 patients with cancer, 15% and 6% experienced high financial burden exceeding 10% and 20% of family income, respectively. Compared with those without high financial burden, patients with cancer with high financial burden were more likely to have significantly lower HRQOL and a greater tendency toward nonspecific psychological distress. Higher levels of financial burden were associated with lower HRQOL, with a stronger relationship observed with physical health than with mental health and a greater tendency toward nonspecific psychological distress. Depressed mood was not significantly associated with high financial burden. CONCLUSION High financial burden among patients with cancer was significantly associated with lower HRQOL and poor mental health. Along with efforts to reduce health care costs for cancer survivors, additional interventions are necessary to ensure the HRQOL and psychological health of cancer survivors.

Exploring factors associated with asthma-related emergency department visits among adults: A path analysis approach

Background The U.S. Agency for Healthcare Research and Quality (AHRQ) developed a hospital patient safety culture survey in 2004 and has adapted this survey to other healthcare settings, such as nursing homes and medical offices, and most recently, community pharmacies. However, it is unknown whether safety culture dimensions developed for hospitals can be transferred to community pharmacies. The aim of this study was to assess the psychometric properties of the Community Pharmacy Survey on Patient Safety Culture. Method The survey was administered to 543 community pharmacists in Wisconsin, USA. Confirmatory factor analysis was used to assess the fit of our data with the proposed AHRQ model. Exploratory factor analysis was used to determine the underlying factor structure. Internal consistency reliabilities were calculated. Results A total of 433 usable surveys were returned (response rate 80%). Results from the confirmatory factor analysis showed inadequate model fit for the original 36 item, 11-factor structure. Exploratory factor analysis showed that a modified 27-item, four-factor structure better reflected the underlying safety culture dimensions in community pharmacies. The communication openness factor, with three items, dropped in its entirety while six items dropped from multiple factors. The remaining 27 items redistributed to form the four-factor structure: safety-related communication, staff training and work environment, organisational response to safety events, and staffing, work pressure and pace. Cronbachs α of 0.95 suggested good internal consistency. Conclusions Our findings suggest that validation studies need to be conducted before applying safety dimensions from other healthcare settings into community pharmacies.

Contextual factors influencing medication management by rural informal caregivers of older adults

Background: There is growing interest in utilizing community pharmacies to support opioid abuse prevention and addiction treatment efforts. However, it is unknown whether the placement of community pharmacies is conducive to taking on such a role. Objective: To examine the distribution of community pharmacies in Wisconsin and its relationship with the location of addiction treatment facilities and opioid‐related overdose events in rural and urban areas. Methods: The total number of opioid‐related overdose deaths and crude death rates per 100,000 population were determined for each county in Wisconsin. Substance abuse treatment facilities were identified in each county to estimate access to formal addiction treatment. A list of pharmacies in the state was screened to identify community pharmacies in each county. Descriptive statistics and Pearson correlation coefficients were used to describe the distribution of and relationships between county‐level opioid‐related overdose death rates and the number of treatment facilities and community pharmacies in the state. Results: Wisconsin has 72 counties, of which 45 (62.5%) are classified as rural. Although the number of opioid‐related overdose deaths was highly concentrated in urban areas, crude death rates per 100,000 population were similar in urban and rural areas. Rural counties were significantly less likely to have formal substance abuse treatment facilities (r = −.42, P = .00) or community pharmacies (r = −.44, P = .00) compared to urban counties. However, community pharmacies were more prevalent and more likely to be located in rural counties with higher rates of opioid‐related overdose deaths than substance abuse treatment facilities. All but 1 of the 14 counties without a formal substance abuse treatment facility had access to 1 or more community pharmacies. Conclusions: Community pharmacies are ideally located in areas that could be used to support medication‐assisted addiction treatment efforts, particularly in rural areas lacking formal substance abuse treatment facilities.