Marc L. Fleming

A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan

BACKGROUND Patients with comorbid hypertension (HTN) and diabetes mellitus (DM) are at a high risk of developing macrovascular and microvascular complications of DM. Controlling high blood pressure can greatly reduce these complications. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with both DM and HTN by the American Diabetes Association guidelines, and their benefit and efficacy in reducing macrovascular and microvascular complications of DM have been well documented. Poor adherence, however, remains a significant barrier to achieving full effectiveness and optimal outcomes. OBJECTIVE To examine the effect of a brief pharmacist telephone intervention in identifying adherence barriers and improving adherence to ACEI/ARB medications among nonadherent patients with comorbid HTN and DM who are enrolled in a Medicare Advantage plan. METHODS Cigna-HealthSprings medical claims data was used to identify patients with HTN and DM diagnoses by using ICD-9-CM codes 401 and 250, and at least 2 fills for ACEIs or ARBs between January 2013 and October 2013. Patients who failed to refill their medication for more than 1 day and had a proportion of days covered (PDC) < 0.8 were considered nonadherent and were contacted by a pharmacist by phone to identify adherence barriers. Two outcome variables were evaluated: The first was adherence to ACEIs/ARBs, defined as PDC during the 6 months following the phone call intervention. The second outcome variable was a categorical outcome of discontinuation versus continuation. Discontinuation was defined as not using ACEIs/ARBs during the 6-month post-intervention period. Patients who disenrolled from the plan in 2014 or were switched to another medication commonly used for treating DM and HTN were excluded from further analysis. Descriptive statistics were conducted to assess the frequency distribution of sample demographic characteristics at baseline. Multiple linear regression was conducted to assess the intervention effect on adherence during the 6 months post-intervention using the first outcome of post-intervention PDC, adjusting for baseline PDC and other covariates. Logistic regression was performed to assess the association between medication discontinuation and other baseline characteristics using the second outcome of discontinuation. Other control variables in the models included demographics (age, sex, language), physician specialty (primary care vs. specialist), health plan (low-income subsidy vs. other), Centers for Medicare & Medicaid risk score, Charlson Comorbidity Index, and number of distinct medications. RESULTS In total, 186 hypertensive diabetic patients, nonadherent to ACEIs/ARBs (PDC < 0.8), were included in the study. Of the 186 patients, 87 received the pharmacist phone call intervention. Among these patients, forgetfulness (25.29%) and doctor issues, such as having difficulty scheduling appointments (16.79%), were the most commonly reported barriers. After excluding those who switched from ACEIs/ARBs to another medication, 157 patients were included in the logistic regression model. Of those, 131 had continued using ACEIs/ARBs and were included in the linear regression model. The mean (±SD) post-intervention PDC for the intervention group was 0.58 (±0.26) and for the control group 0.29 (±0.17). Intervention was a significant predictor of better adherence in the linear regression model after adjusting all the other baseline covariates (β = 0.3182, 95% CI = 0.19-0.38, P < 0.001). Other covariates were not significantly associated with better adherence. In the logistic regression model (discontinuation: 26 [yes]/131 [no]) for predicting medication discontinuation, patients who received intervention were more likely to continue using ACEIs/ARBs (OR = 3.56, 95% CI = 1.06-11.86), and those with a higher comorbidity index were less likely to continue using them (OR = 0.72, 95% CI = 0.53-0.99). CONCLUSIONS The brief pharmacist telephone intervention resulted in significantly better PDCs during the 6 months following the intervention as well as lower discontinuation rates among a group of nonadherent patients with comorbid HTN and DM. The overall PDC rates in both the intervention and control groups were still lower than the recommended 80%. Improving adherence to clinically meaningful values may require more than a brief pharmacist phone call. Incorporating motivational interviewing techniques with follow-up calls to address adherence barriers may be more influential in forming sustainable behavioral change and enhancing medication adherence.

Prescribers and Pharmacists Requests for Prescription Monitoring Program (PMP) Data: Does PMP Structure Matter?

ABSTRACT Prescription monitoring programs (PMPs) have been purported to be an effective tool to combat prescription drug abuse. However, utilization rates of PMP data by health care providers (e.g., prescribers and pharmacists) is relatively low. The objectives of the study were to describe (1) PMP utilization (e.g., requested reports) by prescribers, pharmacists, and law enforcement for active state PMPs; (2) PMP utilization by health care providers with and without online access; (3) average annual operational costs for PMPs from 2008 to 2009; and (4) PMP requests based on PMP housing authority (law enforcement vs. non-law enforcement [e.g., board of pharmacy]). This was a cross-sectional study employing a Web-based survey. A 16-item questionnaire was e-mailed to the 33 operational state PMP administrators and responses were collected from January to March 2011. Descriptive statistics were used to describe PMP request rates and annual operating costs. The usable survey response rate was 45.5%. Among all authorized users, prescribers had higher mean (±SD) requests per 100,000 population (2198.2 ± 3218.0) compared with pharmacists’ requests (268.9 ± 261.2). Online accessibility resulted in higher request rates per 100,000 population (2996.4 ± 3021.5) compared with mail/fax access (14.6 ± 2.8). On average, PMP annual costs were

To Prescribe Codeine or Not to Prescribe Codeine

12,515 ±

Comparative Effectiveness of Second-Generation Antidepressants in Reducing the Risk of Dementia in Elderly Nursing Home Residents with Depression.

14,911 per 100,000 population. In law enforcement–governed PMPs, health care provider utilization was lower compared with PMPs under health or pharmacy boards. Prescriber request rates were higher than pharmacists and online access for providers (e.g., prescribers and pharmacists) resulted in higher request rates per 100,000 population. More research is needed to determine other factors that may be associated with PMP utilization by prescribers and pharmacists.

Education, training, and academic experience of newly hired, first-time pharmacy faculty members.

ABSTRACT A recently published study in Pediatrics by Kaiser et al. (2014; Epub April 21, DOI: 10.1542/peds.2013-3171) reported that on average, over the past decade, children aged 3 to 17 were prescribed approximately 700,000 prescriptions for codeine-containing products each year in association with emergency department (ED) visits. Although, guidelines from the American Academy of Pediatrics issued warnings in 1997 and reaffirmed their concerns regarding the safety and effectiveness of codeine in 2006, it is still often prescribed for pain and cough associated with upper respiratory infection. With the impending rescheduling of hydrocodone combination products to Schedule II, physicians and mid-level prescribers may be compelled to prescribe codeine-containing products (e.g., with acetaminophen) due to reduced administrative burden and limits on Schedule II prescriptive authority for nurse practitioners and physician assistants in some states. This commentary expounds on the safety and effectiveness concerns of codeine, with a primary focus on patients in the ED setting.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence

Second‐generation antidepressants have been shown to improve cognition and depression symptomatology, which are the major risk factors for dementia; however, little is known about the comparative effectiveness of antidepressants in reducing the risk of dementia. Thus, the objective of this study was to evaluate the long‐term comparative effectiveness of different antidepressant classes in reducing the risk of dementia in elderly nursing home residents with depression.

Improving Information Processing The Effect of Label Format Among Current and Potential Over-the-Counter Medication Users

Objective. To describe the education, training, and academic experiences of newly hired faculty members at US colleges and schools of pharmacy during the 2012-2013 academic year. Methods. A survey regarding education, training, and academic experiences was conducted of all first-time faculty members at US colleges and schools of pharmacy hired during the 2012-2013 academic year. Results. Pharmacy practice faculty members accounted for the majority (68.2%) of new hires. Ambulatory care was the most common pharmacy specialty position (29.8%). Most new faculty members had a doctor of pharmacy (PharmD) as their terminal degree (74.8%), and 88.3% of pharmacy practice faculty members completed a residency. Of new faculty members who responded to the survey, 102 (67.5%) had at least 3 prior academic teaching, precepting, or research experiences. Conclusion. New faculty members were hired most frequently for clinical faculty positions at the assistant professor level and most frequently in the specialty of ambulatory care. Prior academic experience included precepting pharmacy students, facilitating small discussions, and guest lecturing.

Educating Pharmacists on a Prescription Drug Monitoring Program

BACKGROUND Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence. OBJECTIVE To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN. METHODS A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score. RESULTS A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence. CONCLUSIONS Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes. DISCLOSURES This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

Comparative Cognitive Profile of Second-Generation Antidepressants in Elderly Nursing Home Residents With Depression

Objective: To test the effect of current versus 2 experimental label formats on information processing among current and potential over-the-counter (OTC) users. Methods: A cross-sectional survey was conducted in a cohort of adults across a metropolitan community, Houston, Texas. Three labels were designed. We placed a chunk of like information together (uses, direction, other information). Label A (control) followed the format of the existing FDA Drug Facts panel format for an antiallergy medication, label B had warnings placed before, while label C had warnings placed after the chunk. The 2 label designs were compared using the information-processing constructs derived from the OTC Label Evaluation Process Model (LEPM). Results: A multivariate analysis of covariance and Dunnett’s test revealed that the mean scores for constructs of OTC LEPM were significantly better for label C compared to the control and label B (P < .0001). Conclusion: Our label format improved information processing among consumers but only when warning placement was placed at the end in the Drug Facts panel, giving an opportunity for the FDA to consider revising the format of the OTC Drug Facts panel, to improve patient understanding and reciprocally enhance patient safety.

Effect of coverage gap on healthcare utilization among Medicare beneficiaries with chronic obstructive pulmonary disorder

Objective: To provide education to community pharmacists regarding the registration and use of the Texas prescription drug monitoring program (PDMP) and to assess the impact of the education on pharmacists’ perceptions of the PDMP. Method: The study design was a descriptive, pre and post, cross-sectional survey conducted among community pharmacists attending a PDMP education program. The program was designed to present the PDMP as a public health tool available to assist pharmacists with dispensing decisions related to controlled prescription drugs. Results: Of the 24 pharmacists who completed the survey, 23 were already registered to use the PDMP. However, all 23 felt that the program successfully educated users regarding the PDMP and agreed that other community pharmacists would benefit from the program presented. After the program, 14 participants responded they would very likely use the PDMP in the next 30 days. Recognition of the use of PDMPs as a program for both pharmacists and physicians was increased from 12.5% (pre) to 73.9% (post). Conclusion: Pharmacists found the educational program beneficial and they were very likely to use the PDMP in the future. Perceptions of the Texas PDMP were changed from pre- to post-education program, with recognition that a PDMP can be a beneficial tool for pharmacy practice.