Days Of Supply Research Articles

Projected 30-day out-of-pocket and total spending on pancreatic enzyme replacement therapy under Medicare Part D.

401 Background: Pancreatic enzyme replacement therapy (PERT) can reduce symptoms of indigestion and improve nutrition in patients with exocrine pancreatic insufficiency. PERT is under-prescribed, and this may be related to actual costs and prescriber sensitivity to these costs. Thus, we aimed to assess PERT costs. Methods: We used Medicare Part D formulary and pricing files for the first quarter of 2020 to conduct a patient-level modeling study to describe point-of-sale and out-of-pocket costs for each PERT formulation among Part D stand-alone and Medicare Advantage prescription drug plans. We calculated costs across nationwide plans under three scenarios: (1) standard benefit design ($435 deductible and 25% coinsurance after the deductible is met); (2) 25% coinsurance (for fills after the deductible and in the coverage gap until the patient spends $6,350 out-of-pocket); and (3) 5% coinsurance (once catastrophic coverage is reached). PERT doses are identified by the lipase content per capsule (in United States Pharmacopeia, USP, units). We calculated the number of units for each PERT formulation/ dose form that would provide optimally dosed PERT for the average US adult (250,000 USP units of lipase per day), based on guidelines and consensus. We first calculated costs for a single unit of PERT. Next, we calculated the number of units needed daily for each formulation/ dose form to provide optimally dosed PERT, and multiplied it by 30 to generate 30-day requirements and costs. Results: Across 3,974 plans nationwide, five PERT formulations in seventeen different doses were covered by Medicare plans in 2020. The range of lipase content in a single unit ranged from 3,000 to 40,000 USP units, and the per-unit list price ranged from $1.44 to $13.89. The point-of-sale price for a 30-day supply of optimally dosed PERT ranged from $2,109 to $4,840. For patients, the expected out-of-pocket costs for a 30-day supply of optimally dosed PERT averaged $999 across formulations (range, $853 to $1536) for those paying a deductible and coinsurance, $673 (range, $527 to $1210) for fills made after meeting the deductible until reaching catastrophic coverage, and $135 (range, $105 to $242) after reaching catastrophic coverage. Conclusions: In this analysis of 2020 Medicare Part D plans, the estimated out-of-pocket cost for just a 30-day supply of optimally dosed PERT was high— at least $100 in the catastrophic phase and approximately $1,000 in the initial phase. In the setting of pancreas cancer, already associated with heavy symptom burden and distress, the financial burden from a supportive care intervention (such as PERT) has been underappreciated. These costs may serve as a barrier to Medicare beneficiary drug access and contribute to financial toxicity.

Opioid days’ supply limits: an interrupted time-series analysis of opioid prescribing before and following a Massachusetts law

ABSTRACT Background: In 2016, Massachusetts passed the first-in-the-nation law limiting opioid naïve adults and all minors to a 7-day supply of opioids when prescribed in the outpatient setting. Objective: We hypothesized this policy would be associated with declines in the percent of opioid prescriptions with more than a 7-day supply among opioid naïve adults and minors for select prescriber groups. Methods: Interrupted time series analyses were conducted using measures from the Massachusetts Prescription Monitoring Program database for 2015 through 2017 (n = 13,672,325 opioid prescriptions; 54% to females). Outcomes were the monthly percent of opioid prescriptions greater than 7 days’ supply in opioid naïve adults and in minors among select prescriber groups. Model estimates of the pre-policy trend, the average changes in the level pre/post-implementation, and the trend changes post-implementation were assessed. Results: Pre-policy trends showed significant monthly declines in the percent of opioid prescriptions greater than 7 days’ supply for all prescriber groups. Policy implementation was associated with significant reduction in the level for opioid naïve adults among surgeons (−2.92%, p < .01), dentists (−0.23%, p < .01), and general medical providers (−2.22%, p = .04), and for minors among all-included prescribers (−2.97%, p < .01) and surgeons (−3.8%, p < .01). Post-implementation changes in trends were not significant except among opioid naïve adults for dentists (0.02%, p = .04). Conclusion: Within a context of significant reductions occurring in opioid prescriptions greater than 7 days’ supply during this period, the Massachusetts policy was associated with further declines for opioid naïve adults and minors among select prescriber groups.

Total and out-of-pocket costs for PARP inhibitors among insured ovarian cancer patients

ObjectiveTo evaluate total and out-of-pocket costs for poly(ADP-ribose) polymerase (PARP) inhibitors and differences based on insurance characteristics. MethodsWe identified ovarian cancer patients who were prescribed niraparib, olaparib, or rucaparib from the MarketScan (2014–2017) and Surveillance, Epidemiology, and End Results (SEER)-Medicare (2014–2016) databases. Drug costs were estimated for a 30-day supply. Descriptive statistics and Wilcoxon rank sum tests were performed. Results590 commercially insured beneficiaries from MarketScan and 213 SEER-Medicare beneficiaries were prescribed PARP inhibitors for a median 112 days. For commercially insured beneficiaries, median total cost was $13,342 (IQR $12,022–$14,256). Median out-of-pocket cost was $44 (IQR $0–$120) and PARP inhibitors accounted for a median 90.8% of patients' total out-of-pocket drug spending. High-deductible health plan was not associated with higher out-of-pocket costs (N = 570; median $0 vs. $45, P = 0.87). For SEER-Medicare beneficiaries, median total cost was $12,798 (IQR $11,704–$13,180). Median out-of-pocket cost was $370 (IQR $2–$1234) and PARP inhibitors accounted for a median 99.0% of patients' total out-of-pocket drug spending. Out-of-pocket costs were lower for dual-eligible patients with supplemental Medicaid prescription coverage (N = 209; median $1 vs. $911, P < 0.001). ConclusionsAlthough insurers are responsible for a large proportion of PARP inhibitor costs, out-of-pocket costs for PARP inhibitors account for a majority of patients' drug spending. SEER-Medicare beneficiaries had higher out-of-pocket costs than patients with commercial insurance, which was offset for those with supplemental Medicaid prescription coverage.

Evaluation of an opioid risk mitigation initiative for veterans undergoing hip or knee arthroplasty at San Francisco Veterans Affairs Health Care System.

Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS. A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented. Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.

Evaluation of Academic Detailing to Impact Pharmacists’ Compliance with an Outpatient Pharmacy Partial Fill Policy

Background Pharmacists’ compliance with a medication partial fill policy at a Veterans Affairs healthcare system has been underwhelming. Academic detailing, an educational outreach approach conducted by trained health care professionals to improve patient care, is an attractive method for improving pharmacists’ compliance with the policy. Objective To evaluate the impact of academic detailing on pharmacists’ compliance with the partial fill policy. Methods A pre-post analysis was performed to evaluate the impact of academic detailing outreach visits on pharmacists’ compliance with the partial fill policy. Data collection included all partial fill medication orders verified during the study duration. Student’s t-test was used to analyze the change in the day supply of partial fills following the academic detailing intervention. Total partial fill drug expense during the pre- and post-intervention phases was calculated as drug cost plus material cost for each partial fill. Results A total of 36 (97.3%) pharmacists received an academic detailing outreach visit. Total percentage of partial fills limited to a 7-day supply was significantly increased following academic detailing outreach visits (49.2% pre-intervention vs. 84.2% post-intervention, p-value <0.001). Total partial fill drug expense decreased from $12,144.42 to $9,713.50. Percentage of partial fills limited to a 7-day supply remained significant during the 6-month follow-up period (p-value = 0.03). Conclusions Academic detailing is an effective method for improving pharmacists’ compliance with an outpatient pharmacy partial fill policy and decreasing total partial fill drug expense for the pharmacy department.

Telepharmacy and medication adherence in urban areas

BackgroundTelepharmacies, which dispense medications on-site under the supervision of an off-site pharmacist using telecommunication technologies, have been proposed as a means to ameliorate the impact of pharmacy closures and improve access to medications. ObjectivesTo examine whether adherence varies among individuals filling prescription medications through a telepharmacy versus a traditional pharmacy in an urban neighborhood. MethodsWe conducted a retrospective cohort study using dispensing records of a traditional pharmacy and a telepharmacy, located in the same low-income Chicago neighborhood, from January 2016 to December 2018. We focused on individuals using statins (n = 1044), angiotensin-converting enzyme inhibitors (ACEs)/angiotensin II receptor blockers (ARBs) (n = 1003), or noninsulin diabetes medications (NIDMs) (n = 692). We defined adherence as a proportion of days covered greater than 80% over 12-months. We examined the association between telepharmacy use and medication adherence using logistic regressions adjusted for demographics (age and sex) and index prescription characteristics (method of payment, e-prescription, 90-day supply). ResultsTelepharmacy users were less adherent to statins (37.6% vs. 54.3%, adjusted odds ratio 0.54 [95% CI 0.38–0.76], P < 0.01) and ACEs/ARBs (41.4% vs, 56.5%, 0.61 [0.44–0.84], P < 0.01) than users of the traditional pharmacy. However, adherence to NIDMs was similar among users of the tele- and traditional pharmacies (65.5% vs. 60.1%, 1.47 [0.92–2.35], P = 0.11). Our findings were similar when we conducted a series of sensitivity analyses, including restricting our cohorts to those who only used their index pharmacy and analyzing cohorts of new rather than continuing users of these medications. ConclusionIn this analysis, medication adherence was lower among users of telepharmacy than users of a traditional pharmacy in some but not all drug classes examined. Further research is needed to identify whether other interventions to improve adherence, such as longer hours of operation, at-home delivery, or 90-day supply, may be coupled with telepharmacies to increase their use in urban areas.

Effect of an Electronic Health Record \u201cNudge\u201d on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care

BackgroundMultiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload.ObjectiveTo estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes.DesignQuality improvement quasi-experiment, analyzed as interrupted time series.ParticipantsAdult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers.InterventionIn the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription.Main MeasuresProportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions.Key ResultsAcross the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards.ConclusionsAutocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress.Trial Registrationwww.ClinicalTrials.gov protocol 1710018646

Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria.

To determine the availability and affordability of asthma and COPD medicines across Nigeria. This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in≥80% of surveyed pharmacies. Unaffordability was defined as paying>1day's wage (> US$1.68) for a standard 30-day supply of the medicine. The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5days. There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.

Hepatic and cardiovascular safety of acarbose among type 2 diabetes patients with end-stage renal disease: A nationwide population-based longitudinal study

AimTo assess the relationship between acarbose and hepatotoxicity, cardiovascular disease (CVD), and mortality among type 2 diabetes (T2D) patients with end-stage renal disease (ESRD). Methods32,531 T2D patients with ESRD were identified from Taiwan’s National Health Insurance Research Database in 2000~∼2012 and followed up until 2013. 19.3% of subjects were newly initiated with acarbose during the follow-up. The use of acarbose was quantified as the numbers of the 30-day drug’s supplies and dosages (measured by defined daily doses; DDDs), respectively. Time-varying Cox models were applied to evaluate the association of acarbose use with hepatic, cardiovascular and mortality outcomes, with adjustment for patients’ demographics, comorbidities, diabetes severity, and co-medications. ResultsFor each 30-day supply increase in acarbose exposure, the risks of hepatic injury, composite CVD events, and all-cause mortality were significantly lowered by 9% (95% confidence interval: 6–12%), 7% (6–7%) and 7% (7–8%), respectively, while for each 30-day DDD increase in acarbose exposure, the risks for three aforementioned outcomes were significantly reduced by 45% (33–54%), 33% (29–36%) and 35% (32–39%), respectively. In subgroup analyses, the favorable study outcomes of acarbose use were more apparent among patients with more severe diabetes, a longer diabetes duration, or absence of established CVD at baseline. ConclusionAcarbose used in real-world T2D patients with ESRD may have hepatic and cardiovascular safety.

S0364 Variability in Formulation, Shelf-Life, and Cost of Compounded Budesonide for Eosinophilic Esophagitis: Survey of Compounding Pharmacy Practices

INTRODUCTION: Recommended first-line therapy for eosinophilic esophagitis (EoE) includes topical corticosteroids. However, there are currently no Food and Drug Administration (FDA) approved pharmacologic therapies and off-label use can be prohibitively expensive. Compounded budesonide suspension may be a more affordable option, but there is no standardized formulation and little is known about the use of compounded topical steroids for EoE. We aimed to characterize compounding pharmacy practice patterns and costs to patients. METHODS: We conducted a telephone survey of all compounding pharmacies in Michigan identified using directories from the state licensing board and professional societies (Professional Compounding Centers of America, Alliance for Pharmacy Compounding). Pharmacies were queried about practices and costs of compounded budesonide for EoE, including medication concentrations, preferred suspensions or drug vehicle, and cost to patients. RESULTS: Of 68 compounding pharmacies identified, 62 responded (90% response rate) and 19 (31%) had dispensed budesonide suspension for EoE, most often prescribed by gastroenterologists (42%). Only 16% routinely tested the quality and accuracy of their budesonide suspension, but all used United States Pharmacopeia (USP) grade budesonide. The majority (67%) were not aware of and there were wide variations in medium and drug concentrations among the 33% that reported using the preferred formula. Commonly used suspension media were methycellulose gel (28%), Mucolox (17%), Ora-plus, Poloxamer, Syrspend, and water. Cellulose (28%) and xanthan gum (11%) were commonly used thickening agents and flavoring or sweeteners were often added. Medication concentrations varied across facilities (median 2mg/10mL, range 2-5mg/mL, min 0.67mg/mL, max 10mg/mL). A 30-day expiration date was recommended by most (67%), but 28% allowed for 90-day or longer use. Median cost for a 30-day supply was $60 (range $40-$80); 42% reported insurance coverage for some patients. CONCLUSION: Few compounding pharmacies offer budesonide suspension and there are substantial variations in formulations dispensed. Given the lack of standardization and efficacy studies for these varied budesonide suspensions, an FDA-approved topical corticosteroid for EoE would be welcome. However, if such a medication is cost prohibitive, then compounded budesonide may still be a more affordable treatment option.Figure 1.: Compounded budesonide suspension sources in Michigan.

Quality improvement initiative for pain management practices in primary care

In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.

Prolonged opioid use among opioid-naive individuals after prescription for nonspecific low back pain in the emergency department

Low back pain is a leading cause of disability globally. It is a common reason for presentation to the emergency department where opioids are commonly prescribed. This is a retrospective cohort study of opioid-naive adults with low back pain presenting to 1 of 4 emergency departments in Nova Scotia. We use routinely collected administrative clinical and drug-use data (July 2010-November 2017) to investigate the prevalence of prolonged opioid use and associated individual and prescription characteristics. In total, 23,559 eligible individuals presented with nonspecific low back pain, with 84.4% being opioid-naive. Our study population included 4023 opioid-naive individuals who filled a new opioid prescription within 7 days after their index emergency department visit (24.4%). The prevalence of prolonged opioid use after a new opioid prescription for low back pain (filling an opioid prescription 8-90 days after the emergency department visit and filling a subsequent prescription ±30 days of 6 months) was 4.6% (185 individuals). Older age and female sex were associated with clinically important increased odds of prolonged opioid use. First prescription average >90 morphine milligram equivalents/day (odds ratio 1.6, 95% confidence interval 1.0-2.6) and greater than 7-day supply (1.9, 1.1-3.1) were associated with prolonged opioid use in adjusted models. We found evidence of declining opioid prescriptions over the study period, but that 24.3% of first opioid prescriptions in 2016 would not have aligned with current guideline recommendations. Our study provides evidence to support a cautious approach to prescribing in opioid-naive populations.

145. The impact of Michigan's new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC)

BACKGROUND CONTEXT In response to the opioid abuse epidemic, the state of Michigan passed new legislation designed to limit use of narcotics. Specific requirements included patient education with attestation, prescription system query, 7-day supply limit for acute pain, and a bona fide prescriber-patient relationship. The major aspects of these opioid laws were effective beginning July 1, 2018. PURPOSE To evaluate the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery. STUDY DESIGN/SETTING Patient data from 1 year prior to and 1 year after initiation of the new opioid laws were queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) database, a spine-specific registry. PATIENT SAMPLE Michigan Spine Surgery Improvement Collaborative (MSSIC) Registry. OUTCOME MEASURES Patient-Reported Outcomes Measurement Information System (PROMIS) short form Physical Function (PF) 4a. METHODS The MSSIC registry prospectively enrolls patients undergoing surgery for degenerative spine disease. Prior to and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated. Chi-square and t-tests were used to examine differences between pre and postopioid law implementation. RESULTS Pre- and postopioid law patients had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3,783 (48.7%) to 2,698 (39.7%), P CONCLUSIONS There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Widening Disparities Among Patients With Rheumatic Diseases in the COVID-19 Era: An Urgent Call to Action.

Recent data from multiple public health departments across the U.S. highlighting the disproportionate burden of COVID-19 infections in vulnerable populations serve as an urgent call to action. As rheumatologists, we are acutely aware of the higher morbidity and mortality, and for a number of our diseases, the higher incidence and prevalence among racial/ethnic minorities and individuals of lower socioeconomic status (SES). Comorbidities are frequent, timely access to subspecialty care is limited, receipt of high quality care is less common, and care is more often fragmented with frequent, avoidable acute care use.

Association of Emergency Department Opioid Administration With Ongoing Opioid Use: A Retrospective Cohort Study of Patients With Back Pain.

Opioids are commonly administered in the emergency department (ED) and prescribed for the treatment of back pain. It is important to understand the unintended consequences of this approach to inform treatment decisions and the consideration of alternative treatments. Recent evidence has shown that ED opioid prescriptions are associated with future opioid use. The objective of this study was to measure the association of opioid administration in the ED to patients treated for back pain with future opioid use. This is a retrospective study of opioid-naïve adults discharged from the ED with a diagnosis of back pain. Patients were stratified by opioid therapy (none, ED administration only, prescription only, or ED administration+prescription). Relative risks of ongoing opioid use (filling >90-day supply in 180days following ED visit as documented in the prescription drug monitoring program) were calculated for each opioid-therapy group and compared to the no-opioid group. We identified 24,487 opioid naïve back pain patients. The median age was 38years, 55% were female, and 56% were non-Hispanic white. A total of 41% received no opioid, 10% were only administered an opioid in the ED, 18% only received a prescription, and 31% received an opioid in the ED+prescription. The adjusted relative risks of ongoing use compared to the no opioid group were as follows: ED only 1.9, prescription only 2.1, and ED+prescription 2.3. The increased risk persisted for other definitions of ongoing use and after adjustment for baseline pain scores. For opioid-naïve patients with back pain, both administration of an opioid in the ED and opioid prescriptions are associated with a doubling of the risk of ongoing opioid use compared to patients not treated with opioids. This supports the consideration of minimizing exposure to opioids while treating back pain in the ED.

Home Dialysis in the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 pandemic has had a significant impact on patients with end-stage kidney disease and their care, especially given the potential for severe coronavirus disease 2019 in those with a depressed immune status. Patients receiving in-center hemodialysis have been particularly affected by this pandemic because of their need to travel multiple times a week to receive treatment. Although patients on home dialysis are able to avoid such exposure, they face their own unique challenges. In this review, we will discuss the challenges posed by the coronavirus disease 2019 pandemic for patients on home dialysis, the impact of coronavirus disease 2019 on various aspects of their care, and the resultant rapid adaptations in policy/health-care delivery mechanisms with implications for the future care of patients on home dialysis.

Older adults’ strategies for obtaining medication refills in hypothetical scenarios in the face of COVID-19 risk

ObjectiveTo determine whether older adults would avoid going to the pharmacy (e.g., by restricting medications or requesting delivery) due to the risk of coronavirus disease (COVID-19). Our secondary objectives were to determine the types of medications that the older adults are more likely to restrict and to determine the factors that influence these decisions. DesignCross-sectional survey experiment in which participants read 6 scenarios, each stating that they had a 3-day supply of a particular medication remaining. Setting and participantsNational Web-based survey distributed to 1457 U.S. adults aged 65 years and older by Dynata from March 25, 2020, to April 1, 2020. Outcome measuresParticipants reported whether they would go to a pharmacy, have a medication delivered, or restrict the use of each medication. They reported their perceptions and experiences with COVID-19, health risk factors, preferences for more or less care (medical maximizer-minimizer), medication attitudes (beliefs about medicines questionnaire), health literacy, prescription insurance status, and demographics. ResultsMost participants (84%) were told to shelter in place, but only 12% reported attempting to obtain extra medications. Participants most often reported that they would go to the pharmacy to obtain each medication (ranging from tramadol 48.9% to insulin 64.9%) except for zolpidem, which they were most likely to restrict (45.4%). Participants who reported comorbidities that increased their risk of COVID-19 were just as likely to go to the pharmacy as those without. In multinomial logistic regression analyses, women and the oldest participants were more likely to seek delivery of medications. Restricting medications was most common for 2 symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizing-minimizing preferences) were associated with such decisions. ConclusionMany older adults intend to continue to go to the pharmacy to obtain their medications during a pandemic, even those who have health conditions that further increase their risk for COVID-19.

1162-P: Coverage, Formulary Restrictions, and Average Retail Prices of SGLT2 Inhibitors and GLP-1 Receptor Agonists across Medicare Part D Plans in 2019

Access to SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1RA) may be limited by high drug prices and insurance related barriers including prior authorization or step therapy requirements. These barriers are particularly challenging for seniors covered under Medicare’s prescription drug benefit (Part D). We used Q1 2019 national Part D Formulary files to examine: 1) the proportion of plans (weighted by enrollment) that cover a SGLT2i or GLP-1RA without prior authorization or step therapy and 2) the average retail price [IQR] for a 30-day supply of each medication. Among 3,992 plans (enrolling at least 37,980,936 beneficiaries), weighted coverage without prior authorization or step therapy for canagliflozin, dapagliflozin and empagliflozin was 53.2% (95% CI: 49.1 to 57.4), 63.7% (95% CI: 60.1 to 67.3) and 95.4% (95% CI: 94.3 to 96.4), respectively. Coverage without prior authorization or step therapy for GLP-1RA of ranged from 3.2% (95% CI: 1.8 to 4.6) for lixisenatide to a high of 87.4% (95% CI: 85.5 to 89.3) for dulaglutide. The mean retail price [IQR] for a 30-day supply of a SGLT2i or a GLP-1RA ranged from $295 [$285-$303] (ertugliflozin) to $512 [$501-$527] (canagliflozin) and $641.38 [$629-$657] (lixisenatide) to $946.17 [$930-$968] (liraglutide), respectively. In 2019, coverage without prior authorization and step therapy for SGLT2i and GLP-1RA were mixed across Part D plans. Most beneficiaries enrolled in plans that covered at least one SGLT2i and one GLP-1RA without restrictions. Cost sharing (i.e., high out-of-pocket payments) may be more problematic for patients than either prior authorization or step therapy. Disclosure J. Luo: Consultant; Self; Alosa Health. R. Feldman: None. S.D. Rothenberger: None. W.F. Gellad: None. Funding National Center for Advancing Translational Sciences (KL2TR001856)

Abstract B081: How patient cost sharing of tyrosine kinase inhibitors affects initiation, adherence, and outcomes in patients with newly diagnosed chronic myeloid leukemia: A retrospective claims-based study

Abstract Background: High out-of-pocket costs may lead to disparities in the initiation of and subsequent adherence to expensive medications. For newly diagnosed chronic myeloid leukemia (CML) patients, early access to tyrosine kinase inhibitors (TKI) is a consistent predictor of adherence and optimal response. The study examines the association between TKI out-of-pocket costs, initiation, adherence, and total health care utilization and costs among patients who initiated TKI within 12 months following first CML diagnosis. Methods: Individuals aged 18 to 64 with an initial diagnosis of CML were identified in the Truven Health MarketScan® Commercial Claims and Encounters database between 1/1/2011 and 12/31/2015. The association between cost sharing and TKI initiation was evaluated using Cox proportional hazards regression models applied to early (patients receiving therapy within 6 months of diagnosis) and late initiators (6-12 months after diagnosis). The association between initiation, adherence, utilization, and costs was examined in a subset of the sample with continuous enrollment for 12 months following TKI initiation. Adherence was estimated using the proportion of days covered (PDC), defined as the percentage of the proportion of days covered by the prescription fill during the 12-month follow-up period (adherent patients have PDC ≥80%). Health care utilization was compared using negative binomial regression models. Health care cost differences between early and late initiators were estimated using generalized linear models. All models were controlled for potential confounding factors. Results: The study sample consisted of 624 patients, 607 (97.3%) early initiators and 17 late. Patients with late initiation had higher TKI out-of-pocket costs (≥75th percentile in the distribution of costs) for the initial 30-day supply (HR=0.83; p=0.047). Among 479 patients who were continuously enrolled during the 12-month follow-up period from TKI initiation, 472 (98.5%) initiated TKI within 6 months. Early initiators had a twofold increase in predicted PDC (75.4% vs. 36.2%; p&amp;lt;0.001). Over the 12-month follow-up period, early initiators incurred $34,075 more in total annual health care costs (p=0.002); cost differences were mainly driven by a TKI pharmacy cost difference of $31,929 (p&amp;lt;0.001). Late initiators were much more likely to have all-cause hospitalizations (IRR=5.94; p=0.026), or CML-specific hospitalizations (IRR=6.94; p=0.019). Conclusions: Higher out-of-pocket costs for TKI may lead to delays in initiation and nonadherence. Patients with early initiation of TKI and adherence had lower nonmedication health care costs that were more than offset by higher TKI medication costs. Findings suggest that high drug out-of-pocket costs may limit access to life-saving oral cancer medications, causing disparities in TKI initiation and adherence for CML treatment. The timeliness of TKI initiation, however, was not shown to lead to overall cost savings during a 12-month follow-up period. Citation Format: Hsiao Ling Phuar, Charles E. Begley, Trudy M. Krause, Wenyaw Chan. How patient cost sharing of tyrosine kinase inhibitors affects initiation, adherence, and outcomes in patients with newly diagnosed chronic myeloid leukemia: A retrospective claims-based study [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B081.

Cost Reduction Associated with Comprehensive Medication Reviews in a Student-Run Free Clinic

Background: Patients taking multiple medications are at increased risk for drug-drug interactions, adverse drug effects, and increases in drug costs. Patients of low socioeconomic status and health literacy have further risk for experiencing these unwanted effects. This study aimed to determine if student-pharmacist led comprehensive medication reviews (CMRs) for patients of a student-run free clinic on multiple chronic medications decreased drug costs and inappropriate overprescribing of medications. Secondary objectives included determination of most overprescribed medication classes and the number and types of recommendations made by student-pharmacists.&#x0D; Methods: Student-pharmacists conducted CMRs on consenting patients seen during a weekly student-run free clinic at a rural university clinic. Included patients were taking six or more chronic medications for two or more chronic disease states at the start of the visit. Information from patient interviews was used to make drug therapy recommendations to interprofessional student teams and an attending provider. Accepted recommendations were implemented into patients’ care plans. The average 30-day drug costs of patients’ medications before and after receiving a CMR were calculated using average wholesale prices and compared using paired t-tests. The most common drug classes recommended to be deprescribed and the total number of accepted recommendations (in the categories of safety, efficacy, and indication) were collected from forms used during CMR.&#x0D; Results: A total of 31 CMRs were completed during the study period, with 92 recommendations made by students and 91% of recommendations accepted by the attending. Average drug costs for a 30-day supply of medication decreased from $698.16 pre-CMR to $619.31 post-CMR, a cost reduction of $78.85 (p = 0.049). The most common recommendations made by students were removal of an unnecessary drug (N = 27), dose too low (N = 15), and additional drug needed (N = 13). The two most overused classes of medications were selective serotonin reuptake inhibitors and proton pump inhibitors.&#x0D; Conclusions: Student-pharmacist led CMRs conducted in a rural free clinic population resulted in a significant decrease in drug spending and identification of drug therapy problems.