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Background: Individuals with rheumatoid arthritis (RA) are at high risk for depression because of the overall burden of systemic inflammation. Although some evidence suggests that treatment with powerful anti-inflammatory drugs, such as tumor necrosis factor (TNF) inhibitors, may be effective in reducing the risk for depression in patients with RA, it is unclear whether such reduction in risk is dependent on the response to TNF inhibitor therapy.

Objective: To evaluate the association between the response to TNF inhibitor therapy and the risk for depression among working-age adults with RA.

Method: This retrospective, observational cohort study design was based on data derived from commercial claims data in the QuintilesIMS Real World Data Adjudicated Claims database between October 1, 2009, and September 30, 2015. A total of 4222 working-age adults (18-62 years) with RA who started treatment with TNF inhibitor therapy and were continuously enrolled during the 3 observation periods (ie, 1-year baseline, 1-year treatment, and 1-year follow-up periods) were included in the study. Treatment response to a TNF inhibitor was measured using prescription drug claims based on a published validated algorithm. Multivariable logistic regression was used to examine the association between treatment response to TNF inhibitor therapy and the risk for depression, after controlling for baseline demographic characteristics, clinical characteristics, and RA-related medication use. An inverse probability of treatment weighting technique was used to control for observable differences in TNF inhibitor responders' characteristics versus TNF inhibitor nonresponders.

Results: Overall, 359 (8.5%) patients with RA had depression during the follow-up period and 1679 (39.8%) patients responded to TNF inhibitor treatment during the 1-year treatment period. A significantly lower percentage of TNF inhibitor responders (7.1%, N = 119) had depression than TNF inhibitor nonresponders (9.4%, N = 239). After controlling for other risk factors, responders to TNF inhibitors were 20% less likely to have depression during the follow-up period (adjusted odds ratio, 0.80; 95% confidence interval, 0.64-0.98) than nonresponders to TNF inhibitor therapy.

Conclusion: The risk for depression was significantly reduced among patients with RA who responded to TNF inhibitor therapy compared with those who did not respond to such therapy. To determine whether the lower rate of depression observed with TNF inhibition is a direct effect of treatment with a TNF inhibitor, or whether it could be attributed to improvement in RA disease secondary to treatment, future studies need to also incorporate a control population of patients with RA who receive other antirheumatic regimens, such as disease-modifying antirheumatic drugs.

Background: The Medicaid Drug Utilization Review (DUR) program is a 2-phase process conducted by Medicaid state agencies. The first phase is a prospective DUR process and involves electronically monitoring prescription drug claims to identify prescription-related problems, such as therapeutic duplication, contraindications, incorrect dosage, or duration of treatment. The second phase is a retrospective DUR involving ongoing, periodic examinations of claims data to identify patterns of fraud, abuse, underutilization, drug-drug interaction, and medically unnecessary care, and implement corrective actions when needed. The Centers for Medicare & Medicaid Services requires each state to measure the prescription drug cost-savings generated from its DUR programs annually, but it provides no methodology for doing so. An earlier article compared the methodologies used by states to measure cost-savings in their retrospective DUR program in fiscal years 2014 and 2015.

Objective: To describe and synthesize the methodologies used by states to measure cost-savings using their Medicaid prospective DUR program in federal fiscal years 2015 and 2016.

Methods: For each state, we downloaded from Medicaid's website the cost-savings methodologies included in the Medicaid DUR 2015 and 2016 reports. We then reviewed and synthesized the reports. Methods described by the states were classified into a unique group based on the methodology used, except for Arkansas and Connecticut, which were classified in more than 1 category for the same period.

Results: Currently, 3 different methodologies are being used by states. In 2015 and 2016, the most common methodology used (by 18 states) was the calculation of total claim rejections and subtracting claim resubmissions at the amount actually paid. The comparisons of DUR program cost-savings among states are unreliable, because the states lack a common methodology in the way they measure their performance.

Conclusions: Considering the lack of methodologic consistency among states in measuring the savings in the Medicaid DUR program shown in this analysis, the federal government must lead an effort to define a unique methodology to measure cost-savings in its entire DUR program. This will help to improve the measure of savings among states and understand how this program is performing in that matter.

Background: Community-acquired bacterial pneumonia (CABP) is an acute, lower respiratory bacterial infection. Despite advances in medical care, CABP remains associated with considerable morbidity, mortality, and healthcare costs; early empiric treatment is recommended by the Infectious Diseases Society of America and by the American Thoracic Society. Omadacycline is an oral and intravenous (IV) once-daily aminomethylcycline antibiotic that is approved in the United States for the treatment of adult patients with CABP.

Objective: To estimate the budget impact of introducing omadacycline as a treatment option among patients with suspected or documented CABP from a US hospital perspective.

Methods: A budget impact model was developed in Microsoft Excel^® 2010. Population, clinical, and cost inputs were based on the available literature, clinical trial data, and real-world evidence databases. Emergency departments and observation units were assumed to be hospital-owned as part of the analyses. Sensitivity analyses assessed the impact of key parameters on the model results, and scenario analyses were explored to analyze the budget impact of reducing length of hospital stay and avoiding hospitalization.

Results: The introduction of omadacycline as a treatment resulted in a total budget increase of $20,643 over 3 years. This increase was mainly attributed to treatment acquisition costs. In a scenario where the length of hospital stay was reduced by 1 day (under the assumption that an antibiotic with IV and oral formulations can facilitate earlier discharge from inpatient care), the 3-year total budget decreased to $2384; reducing the hospital stay by 2 days resulted in 3-year cost-savings of $15,875. Shifting inpatient care to the outpatient setting with omadacycline resulted in 3-year cumulative cost-savings of $112,843.

Conclusion: This is the first omadacycline budget impact model developed for adult patients with suspected or documented CABP. The model projected a modest budget increase with the introduction of omadacycline, mainly due to treatment acquisition costs.

Background: Cataracts are the leading cause of preventable blindness globally. As a result, competence in cataract surgery is an important component of ophthalmology residency training. Residency programs must optimize the number of cataract surgery cases to train proficient physicians. However, the rate of cataract surgery cancellations is high, and some are canceled because of preventable causes.

Objective: To evaluate the effect of mandatory on-site preadmission testing, including having a physical examination, on resident-performed cataract surgery cancellation rates.

Methods: For this study, patients scheduled for cataract surgery at the Wills Eye Hospital resident cataract clinic between January 2015 and November 2015 were enrolled and randomized into 2 groups: usual care or intervention. The patients randomized to the usual care group were instructed to complete preadmission testing and to have a physical examination with their primary care physician. The patients randomized to the intervention group were escorted to a Wills Eye Hospital-affiliated cardiologist to complete preadmission testing and to have a physical examination. Patients in both groups received a reminder call before the cataract surgery.

Results: A total of 441 patients were included in the study-240 patients in the usual care group and 201 patients in the intervention group. The overall cataract surgery cancellation rate was 14.5%; the rate was 12.4% in the intervention group and 16.3% in the usual care group (P = .28). The patients receiving the intervention were more likely to have preadmission testing and a physical examination than the patients in the usual care arm (P <.001).

Conclusions: Facilitating the completion of preadmission testing for patients decreased the rates of resident-performed cataract surgery cancellation at a Wills Eye Hospital resident clinic and has the potential to improve patient outcomes and prevent blindness.

Background: Drug therapy problems, which are adverse events involving medications that can ultimately interfere with a patient's therapeutic goals, occur frequently in older adults. If not identified, resolved, and prevented through clinical decision-making, drug therapy problems may negatively affect patient health outcomes.

Objective: To quantify the impact of pharmacist interventions on the care of older adults by identifying the most common drug therapy problems, the medications most often involved in these problems, and the actions taken by pharmacists to resolve these problems.

Methods: This retrospective chart review included individuals seen by a geriatric pharmacist in one geriatric practice, where 4 pharmacists provide continuous, comprehensive medication management across 2 outpatient geriatric clinics, skilled-nursing facilities, and assisted-living facilities. The individuals were seen between August 2014 and November 2015. For all patient care encounters during this time frame, pharmacists used the Assurance System to document each drug therapy problem, the medications involved, the patient's care setting (ie, outpatient clinic, assisted-living facility, skilled-nursing facility), the actions taken to resolve any drug therapy problems, and the estimated 90-day impact on the patient and the healthcare system.

Results: A total of 3100 drug therapy problems were identified during 3309 patient-pharmacist encounters for 452 patients (mean age, 81.4 years), 48.7% of whom were seen in the skilled-nursing facility. The most common drug therapy problem was dose too low, followed by dose too high, and warfarin was the most common drug associated with drug therapy problems. Pharmacists provided 4921 interventions, often more than 1 intervention per drug therapy problem, for 275 different medications. Laboratory monitoring and dose change were the most common interventions, with an estimated annual financial savings between $268,690 and $270,591.

Conclusion: Older patients are a vulnerable patient population who often receive unsafe medication regimens, which can result in adverse drug reactions and other critical problems. When integrated into interprofessional geriatric care teams, pharmacists' interventions provide an invaluable qualitative and monetary resource to the medication-based management of patients with well-recognized, high-risk geriatric syndromes as they transition to and through various levels of care.

Background: Omadacycline is an oral and intravenous (IV) once-daily aminomethylcycline antibiotic that was recently approved by the US Food and Drug Administration for the treatment of patients with acute bacterial skin and skin structure infections (ABSSSI). In 2 phase 3 clinical trials, IV-to-oral switch and oral-only administration of omadacycline achieved the primary end points of noninferiority compared with linezolid in treating patients with ABSSSI.

Objective: To estimate the potential cost-savings with bioequivalent IV-to-oral antibiotics, such as omadacycline, compared with the standard of care with IV vancomycin by avoiding hospitalizations and reducing hospital stays in patients presenting from the emergency department for ABSSSI treatment.

Methods: We used hospital avoidance models to examine the potential cost-savings of managing patients with ABSSSI and no or limited comorbidities and without life-threatening conditions by using omadacycline in the outpatient setting compared with the current standard of care. Early hospital discharge models were used to evaluate the hospital stay reduction that would be required to be achieved with omadacycline treatment relative to IV vancomycin to confer cost-savings compared with standard of care among patients with ABSSSI and ≥2 comorbidities but no life-threatening conditions.

Results: In the hospital stay avoidance models, cost-savings may be realized by using therapeutically bioequivalent IV-to-oral antibiotics, such as omadacycline, compared with inpatient treatment with IV vancomycin. Based on a sensitivity analysis, further savings could be possible with outpatient administration of omadacycline, even if 20% of omadacycline outpatients were subsequently admitted and incurred the full inpatient cost, with no reimbursement penalties. Of more than 300 patients, only 1 was admitted to the hospital after a full course of omadacycline in the oral-only clinical trial. In the early hospital discharge models, the maximum cost-minimizing daily expense of omadacycline varied from $173 to $936, depending on the presence of active comorbidities or systemic symptoms, hospital stay reduction, and model perspective.

Conclusion: These results suggest that the targeted use of antibiotics with bioequivalent IV-to-oral formulations, such as omadacycline, for select patients with ABSSSI may lead to cost-savings compared with inpatient IV vancomycin treatment by shifting care to the outpatient setting or by facilitating earlier hospital discharge among hospitalized patients.