Marie A. Chisholm

Impact of clinical pharmacy services on renal transplant patients’ compliance with immunosuppressive medications

Background: Non‐compliance with immunosuppressive medications may result in allograft rejection and is regarded as an important impediment to post‐transplant care. This randomized, controlled trial evaluates the impact of clinical pharmacy services on renal transplant patients’ compliance with immunosuppressive agents. 
Methods: Patients who received a renal transplant at the Medical College of Georgia from February 1997 through January 1999 were randomized in the intervention or control group provided they met study criteria. In addition to routine clinic services at each clinic visit, patients in the intervention group received clinical pharmacy services, which included medication histories and review of patients’ medications with an emphasis on optimizing medication therapy to achieve desired outcomes and minimizing adverse medication events. The clinical pharmacist also provided recommendations to the nephrologists with the goal of achieving desired outcomes. To promote medication compliance by using compliance enhancement strategies, the clinical pharmacist counseled patients concerning their medication therapy and instructed them how to properly take their medications. Patients in the control group received the same routine clinic services as the intervention group except that they did not have any clinical pharmacist interaction. Compliance rate (CR) was calculated and patients compliance status was determined from the CR. The CR, the fraction of patients remaining compliant for each month, and the mean time patients were compliant were compared between groups. Whether there was a difference in the frequency of patients achieving ‘target’ immunosuppressive levels in the control and study groups was evaluated. 
Results: The mean CR for patients who had clinical pharmacist intervention (n=12) was statistically higher than the control groups (n=12) mean CR (p<0.001). During the 12‐month post‐transplant study period, patients in the intervention group had a longer duration of compliance than patients in the control group (p<0.05). Additionally, patients who had clinical pharmacy services had a greater achievement of ‘target’ levels than patients who did not receive these services (p<0.05). 
Conclusions: Patients who received clinical pharmacy services with traditional patient care services had better compliance with immunosuppressants than patients who only received traditional patient care services. Results of this study suggest a multidisciplinary team that includes a clinical pharmacist as part of the care for post‐transplant patients is beneficial for enhancing medication compliance.

Renal transplant patient compliance with free immunosuppressive medications.

Background. Noncompliance with immunosuppressive medications after renal transplantation is believed to be a major cause of allograft rejection and graft loss, with the impressive costs of these agents considered a significant reason for noncompliance. Our purpose was to determine the compliance rates of renal transplant patients who received their immunosuppressant therapy free of charge and evaluate their patterns of compliance. Methods. All patients who received a renal transplant and received their immunosuppressant medications at our institution for their first year posttransplant were included in the study. Compliance rate was calculated and serum immunosuppressant concentrations were obtained to validate compliance assessments. Results. Eighteen patients were included in the study. Approximately 48% of noncompliant patients were found to have subtarget drug concentrations, although only 14% of compliant patients had subtarget levels (&khgr;2=12.9, P <0.001). At 5 months posttransplant, 95% of the patients remained compliant; however, by 12 months posttransplant, only 48% of the patients remained compliant. The mean time to the first noncompliant month was 9.8 months (95% confidence intervals=8.60–11.0). Conclusions. Patients who received their immunosuppressants free of charge were generally compliant within their first year of transplantation, however, compliance tended to decrease over time. This suggests that drug cost alone does not explain noncompliant behavior. Intensive efforts to increase medication compliance before month 8 posttransplantation should be implemented.

Issues of adherence to immunosuppressant therapy after solid-organ transplantation.

Nonadherence to immunosuppressant therapy constitutes a major barrier to post-transplant care. Failure of transplant recipients to take prescribed drugs properly may not only be a significant obstacle to optimal graft function but it may also result in decreased quality of life and productivity, increased morbidity and healthcare cost, and death. Despite the obvious importance of adherence to immunosuppressant therapy, nonadherence is frequent among transplant recipients, with rates ranging from 2 to 68%.This manuscript briefly discusses several issues concerning adherence to immunosuppressant therapy of solid-organ transplant recipients; presents a literature review concerning adherence to immunosuppressant therapy by solid-organ transplant recipients; and suggests strategies that may be used to enhance medication adherence. Although many of the studies have results that conflict concerning factors associated with immunosuppressive nonadherence, most of the investigators concluded that nonadherent behaviour is usually not predictable. Because of possible adverse events, emphasis should be placed on increasing medication adherence in all transplant recipients.

Cost‐benefit analysis of a clinical pharmacist‐managed medication assistance program in a renal transplant clinic

Medicare pays for 80% of the cost of immunosuppressant agents needed within the first 3 years of solid organ transplantation; however, many patients cannot afford the remaining 20%. Furthermore, many patients who are beyond 3 years post‐transplantation and have prescription coverage cannot afford the co‐payment for these medications. Other patients may not be able to afford their medications due to limited or no insurance coverage. The Medical College of Georgia (MCG) has been giving immunosuppressant medications to renal transplant patients if they cannot afford to pay for them. To assist MCG with drug cost for medications and maintain quality care for renal transplant patients, a clinical pharmacist‐managed medication assistance program was implemented to procure immunosuppressants from pharmaceutical manufacturers. 
Methods: All patients enrolled in medication assistance programs from 1 January 1998 through 31 December 1998 were included in this analysis. Medication acquisition costs with and without Medicare reimbursement and the cost of implementing the clinical pharmacist‐managed medication assistance program were used to determine the value of implementing this service. 
Results: Sixty‐one patients were enrolled in manufacturers’ assistance programs and a net cost avoidance of

Comparing renal transplant patients’ adherence to free cyclosporine and free tacrolimus immunosuppressant therapy

124,793 was realized for the year of the program (benefit‐to‐cost ratio of 7.5:1). Assuming that the hospital collected the maximum amount allowed for patients receiving Medicare benefits, a cost avoidance of

Isolating the cost of osteoporosis-related fracture for postmenopausal women. A population-based study.

69,233 was calculated (benefit‐to‐cost ratio of 4.16:1). 
Conclusions: A clinical pharmacist‐managed medication assistance program in a renal transplant clinic produced substantial cost savings over this 1‐year study period. For each dollar spent in pharmacists time, a minimum of

Venous thrombosis after acute spinal cord injury: Cost analysis of prophylaxis guidelines

4 was returned to the institution.

Increasing medication access to transplant recipients

Abstract:  Background:  The purpose of this study is to determine if there is a difference in renal transplant patients’ (RTPs) adherence to cyclosporine compared to tacrolimus when medications are supplied free to the RTPs.

Cost-Effectiveness Analysis of Deep Vein Thrombosis Prophylaxis in Internal Medicine Patients

Background: Osteoporosis is a condition that will pose an increasing burden on health systems as populations age. Objective: The objective of this study was to estimate the net ‘per case’ direct medical cost of fracture of indigent women age 50 years or greater and describe the cost of fracture for Medicaid and Medicare payers by inpatient hospital, physician, long-term care, prescription and miscellaneous expenditures. Methods: This study utilized a quasi-experimental retrospective interrupted time series design to isolate the economic impact of fracture. Administrative claims data for a continuous period of 24 months (12 months prior to fracture and 12 months after fracture) describing the Medicaid and Medicare expenditures for a cohort of women suffering from femur or other fracture in 1993 was abstracted and analyzed. ICD-9CM and CPT-4 codes were used to identify incident cases of fracture. Interrupted time series regression models were estimated using monthly expenditures. Results: A total of 765 Medicaid eligible women 50 years of age or greater experienced a fracture in the base year and met inclusion criteria. Of these, 226 experienced a femur fracture. The time series models detected significant increases in expenditures the month of fracture, however, total Medicaid expenditures returned to baseline trend charge in 7 and 5 months for femur and nonfemur fracture, respectively. Increases in long-term care expenditures persisted throughout the time series, but were offset by reductions in other categories of service. Conclusion: The net per case costs of femur and nonfemur fracture are about USD 3,300 and USD 1,300, respectively. The impact of fracture on Medicaid expenditures is temporary as costs rise sharply and return to baseline trend charges within a 12-month period.

Assistance programs available for medications commonly used in transplant patients

ObjectiveVenous thrombosis and pulmonary embolisms are major complications associated with acute spinal cord injury. The purpose of this study was to perform a cost analysis on the two pharmacoprophylaxis regimens suggested for deep vein thrombosis prophylaxis in this population. MethodsEfficacy and safety data were obtained from the literature. ResultsResults of the cost analysis demonstrates that adjusted dose unfractionated heparin produces a cost savings over enoxaparin at 30 mg every 12 hr. ConclusionFurther studies are needed to determine the most cost-effective therapy for preventing deep vein thrombi in this population.