Stephen J. Kogut

Decreased persistence to cholinesterase inhibitor therapy with concomitant use of drugs that can impair cognition

Study Objectives. To assess persistence with cholinesterase inhibitor therapy 6 months after the start of treatment, and to determine whether the likelihood of persistence is associated with the coprescription of drugs that can impair cognition.

Concomitant use of triptan, and SSRI or SNRI after the US Food and Drug Administration alert on serotonin syndrome.

Objective.— The present study was designed to discern the prevalence of concomitant use of a 5‐hydroxytryptamine receptor agonist (triptan), and a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin/norepinephrine reuptake inhibitor (SNRI) after the US Food and Drug Administration issued an alert regarding serotonin syndrome in 2006 and to contrast findings with data published prior to the federal warning.

Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study

Background Substantial opportunity exists to improve medication management in the period following a hospital discharge. The objective of this study was to assess and improve medication management during care transitions through pharmacist home visits and the use of an electronic personal health record (ePHR) system. Methods Recently discharged patients aged 50 years or older and having a chronic medical condition were offered the opportunity to meet with a pharmacist in the home setting to review medication instructions and receive a demonstration of an ePHR system. Patients agreeable to using the ePHR system were offered pharmacist support with setting up the ePHR system, having emphasis on documenting and reviewing medication regimens. Medication-related problems identified by the pharmacist during the visit were categorized according to ePHR use and by other characteristics. Results Thirty recently discharged patients with chronic disease were visited by a pharmacist over a 6-month period. The percentage of medication-related problems identified by the pharmacist was greater among those patients who agreed to use the ePHR system, as compared with patients whose visit did not include use of the ePHR (75% versus 40%, respectively; P=0.06). Differing types of medication-related problems were identified, including therapy duplications, lack of use of clinically important therapies, and patient nonadherence. Conclusion For some patients, the home setting can be a suitable venue for medication review and education after discharge from hospital. Assisting patients with setting up the ePHR system may enhance pharmacists’ ability to identify and resolve medication-related problems that may lead to rehospitalization.

Comparison of persistence rates of acetylcholine-esterase inhibitors in a state Medicaid program.

Objective To compare levels of persistency between cholinesterase inhibitors (ChEIs) among a Medicaid patient population of older adults. Methods Survival analysis was used to assess differences in discontinuation between ChEIs (donepezil versus rivastigmine and galantamine), and for difference in patient gender, age, race, and care setting. Results Rates of discontinuation increased from 42.7% (95% CI = 39.9–45.5) at 12 months to 84.8% (95% CI = 82.3–87.3) at 24 months. In multivariate models, no significant difference in discontinuation existed prior to 365 days. However, patients dispensed donepezil were less likely to discontinue as compared with users of the other two ChEIs after the first year (RR = 0.70; CI = 0.499–0.983; p < 0.04). Patients of white race were less likely to discontinue (RR = 0.549; 95% CI = 0.43–0.82; p = 0.0015), while gender, care setting, and age were not associated with discontinuation. Conclusions One-year persistence rates were similar between different ChEIs. Among patients persisting with ChEI medication for at least 12 months, users of donepezil were slightly more likely to continue to persist at 24 months. Nearly half of patients failed to persist with ChEI therapy for at least 12 months. Our findings underscore the limitations of the ChEI medications and the urgent need for effective and tolerable therapeutic options for patients having dementia.

Evaluation of Differences in Percentage of International Normalized Ratios in Range Between Pharmacist-Led and Physician-Led Anticoagulation Management Services

Background: The safety and efficacy of warfarin depend on maintaining the international normalized ratio (INR) in an established range. Objective: The purpose was to determine whether a coordinated pharmacist-led approach improved percentage of INRs in therapeutic range in comparison to a physician-led anticoagulation management service (AMS). Methods: A retrospective chart review was conducted for patients at a multisite primary care organization. INR data for patients receiving warfarin management by a physician were collected from December 1, 2009 to May 31, 2010. These were compared to INR results from December 1, 2010 to May 31, 2011, during which patients received warfarin management from a pharmacist. The primary end points were percentage of INRs within a goal range of 2.0 to 3.0 and an expanded goal range of 1.8 to 3.2 for the physician-led group versus the pharmacist-led group. Results: The percentage of INR results within the goal range (2.0-3.0) was greater among patients in the pharmacist-led group (n = .130) than the physician-led group (n = 96; 57.5% vs 50.0%, respectively; P = .0004). The percentage of INR results <1.5 (7.3% vs 5.1%) and >3.5 (11.4% vs 7.1%) was also statistically significant in favor of the pharmacist-led AMS, with P values of .03 and .0004, respectively. Conclusion: A pharmacist-led AMS improved the percentage of INRs in range, with significantly less out-of-range results.

Use of electronic personal health records to identify patients at risk for aspirin-induced gastrointestinal bleeding.

OBJECTIVE(S) The aim of this paper is to describe the utility of electronic personal health records (ePHRs) to identify patients with potential risk factors for aspirin-induced upper gastrointestinal bleeding (UGIB). SETTING ER-Card, LLC. a for-profit ePHR company located in Rhode Island from October 2008 to May 2010. PRACTICE DESCRIPTION Clinical pharmacists reviewed the records of 615 patients enrolled in an ePHR service. Records included patient self-report of all known medical conditions, current prescription medications, and self-care therapies utilized. PRACTICE INNOVATION Pharmacists reviewed ePHR profiles for actual or potential medication-related problems. Patients taking low-dose aspirin (81 mg-325 mg daily) were screened for known additional risk factors for aspirin-induced UGIB. Patients identified were notified to contact their provider for information and/or providers were contacted directly by pharmacists with therapy recommendations. MAIN OUTCOME MEASURE(S) Number of patients at increased risk for aspirin-induced UGIB as a result of concomitant medications. RESULTS Ninety-seven patients (16% of total records screened) with an average age of 72.1 years had risk factors for aspirin induced UGIB. In addition to daily aspirin therapy patients reported regular use of nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors (38%), other antiplatelet agents (22%), anticoagulants (24%), corticosteroids (4%), or a combination of these medications (12%). None of the patients included in this analysis reported use of prescribed or overthe-counter gastroprotective therapy (such as proton-pump inhibitors or histamine-2 receptor antagonists). CONCLUSION Pharmacist screening of patient self-reported health information as part of an ePHR service can result in the detection of a significant number of patients at increased risk for aspirin-induced UGIB.

Computer Kiosks to Deliver Medication Information in the Pharmacy

The feasibility of using a computer kiosk to deliver medication information to patients was tested in a community pharmacy environment. Viewers used a computer kiosk to access the National Library of Medicine (NLM) MedlinePlus® website. In four weeks, 198 pharmacy patients viewed the website and completed brief questionnaires about their experiences. The majority of patients (63%) were female and between 46 and 65 years of age (48%). Few (8%) had used the NLM website before. Patient age was associated with access to the Internet, previous use of the NLM website, and other habits regarding medication information sources; however, the differences were not as great as anticipated.

Real-World Health Care Costs Based on Medication Adherence and Risk of Stroke and Bleeding in Patients Treated with Novel Anticoagulant Therapy

BACKGROUND With the lack of real-world evidence, the challenge for drug reimbursement policy decision makers is to understand medication adherence behavior among users of novel oral anticoagulants (NOACs) and its effect on overall cost savings. No study has examined and quantified the burden of cost in high-risk patients taking NOAC therapy. OBJECTIVE To examine the association of cost with adherence, comorbidity, and risk of stroke and bleeding in patients taking NOACs (rivaroxaban and dabigatran). METHODS A retrospective cohort study used deidentified data from a commercial managed care database affiliated with Optum Clinformatics Data Mart (January 1, 2010-December 31, 2012). Patients aged 18 years and older with ≥ 1 diagnosis of atrial fibrillation/flutter, > 1 NOAC prescription, 6-month pre-index and 12-month post-index continuous enrollment, and CHA2DS2-VASc score ≥ 1 were included. Adherence was calculated using proportion of days covered (PDC ≥ 80%) over an assessment period of 3, 6, and 12 months and compared based on level of comorbidity, stroke, and bleeding risk. The adjusted annual health care costs per patient (drug, medical, and total) were calculated using multivariable gamma regression controlling for demographic and clinical characteristics and compared across groups based on adherence over 12 months, baseline level of comorbidity, and risk of stroke and bleeding. RESULTS Of 25,120 NOAC patients, 2,981 patients were included in the final cohort. Based on a PDC threshold of ≥ 80%, the adherence rate over 3, 6, and 12 months was 72%, 65%, and 54%, respectively. For all time periods, the level of adherence significantly increased (P < 0.001), with an increase in stroke risk (based on CHA2DS2VASc scores of 1, 2-3, and 4+); comorbidity (Charlson Comorbidity Index scores of 0, 1-2, and 3+); and risk of bleeding (HAS-BLED scores of 0-1, 2, and 3+). Adjusted all-cause total cost calculated for a 12-month period was significantly lower (

Estimating the Direct Costs of Outpatient Opioid Prescriptions: A Retrospective Analysis of Data from the Rhode Island Prescription Drug Monitoring Program

29,742 vs.

Impact of medication adherence on risk of ischemic stroke, major bleeding and deep vein thrombosis in atrial fibrillation patients using novel oral anticoagulants

33,609) among adherent versus nonadherent users. Drug cost was higher (