Health-system Specialty Pharmacy Research Articles

Impact of Risk Stratification in Patients With Diabetes Mellitus in a Health System Specialty Pharmacy Setting.

Background: Integrated pharmacist care into health systems results in significant A1c reduction and improved outcomes in patients with diabetes. However, little is known about the adoption of Health System Specialty Pharmacy (HSSP) chronic disease management (CDM) services within diabetes clinics. Risk stratification is proven to enhance care in various patient populations. Objective: The objective of this study is to describe how the implementation of risk stratification in the HSSP setting results in optimized patient outcomes in diabetes. Method: This is a retrospective descriptive study reporting the results of expanding the HSSP care model to implement risk stratified CDM services for patients with diabetes. A total of 285 patients were enrolled in the HSSP CDM pharmacy services and were stratified into high- or low-risk groups. Results: Eighty-eight patients were stratified as high-risk with an average baseline A1c of 11.47% and a most recent average of 8.84%. The remaining 285 patients were stratified into the low-risk group. Their average baseline A1c was 7.48% and the last recorded average A1c was 7.15%. Patients not enrolled in HSSP CDM services (N = 100) had a lower reduction in average A1c compared to patients enrolled in the program. Conclusion: Patients stratified into high- and low-risk groups had greater reductions in A1c compared to patients who did not use HSSP CDM services. These results showcase the success of risk stratification and demonstrate the impact HSSP has on patients needing CDM services and outlines a strategy to provide the greatest impact in a high-volume patient population.

Impact of a health-system specialty pharmacy on time to upadacitinib initiation.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Upadacitinib has been found to improve symptoms as early as day 1 in patients with inflammatory bowel disease. As a result, early and timely initiation of upadacitinib is paramount to prevent hospital admission for an acute flare. The purpose of this study was to identify the time to initiation of upadacitinib, comparing external specialty pharmacies (ESPs) to a health-system specialty pharmacy (HSSP). This was a single-center, retrospective study at the University of Chicago Medicine (UCM) Inflammatory Bowel Disease Center and included patients initiated on upadacitinib between March 1, 2022, and April 1, 2023. Data collected included demographics, prior authorization information, appeal information, insurance type, date the prescription was sent, and date the patient initiated therapy (patients were called to confirm the date). The primary outcome evaluated was the days from prescribing to patient initiation. Secondary outcomes included the total time to initiation and the time to notification from insurance regarding determination of a prior authorization or appeal. Patients were excluded if they were lost to follow-up, initiated therapy through alternative means, or had previously initiated upadacitinib. A total of 107 patients were initiated on upadacitinib during the study period (n = 18 through the UCM HSSP, n = 89 through an ESP). The median number of days to patient initiation was 3 days (interquartile range, 3-6 days) for the UCM specialty pharmacy vs 9 days (interquartile range, 4-13 days) for ESPs (P = 0.003). A total of 88.9% of patients filling through the UCM specialty pharmacy initiated upadacitinib within 7 days, compared to 47.2% of patients filling through an ESP (P = 0.001). Seven patients needed earlier initiation of therapy to prevent hospital admission. This study validates the ability of HSSPs to initiate therapies earlier than ESPs with a particular focus on upadacitinib.

Financial impact of integrated specialty pharmacy efforts to avoid oral anticancer medication waste.

The growing number of oral anticancer medications represents a significant portion of pharmacy spending and can be costly for patients. Patients taking oral anticancer medications may experience frequent treatment changes following necessary safety and effectiveness monitoring, often resulting in medication waste. Strategies to avoid medication waste could alleviate the financial burden of these costly therapies on the payer and the patient. To evaluate the impact on waste and cost avoidance of reviewing the amount of medication patients have on hand and the presence of upcoming follow-up (ie, provider visit, laboratory testing, or imaging) before requesting a prescription refill renewal for patients taking oral anticancer medications through an integrated health system specialty pharmacy. We performed a retrospective review of patients filling oral anticancer medications prescribed by a Vanderbilt University Medical Center provider and dispensed by Vanderbilt Specialty Pharmacy between January 1, 2020, and December 31, 2020. Specialty pharmacists received a system-generated refill renewal request for oral anticancer medications when the final prescription refill was dispensed, prompting the pharmacist to review the patient's medical record for continued therapy appropriateness and to request a new prescription. If the patient had a sufficient supply on hand to last until an upcoming follow-up (ie, provider visit, imaging, or laboratory assessment), the pharmacist postponed the renewal until after the scheduled follow-up. Patients were included in the analysis if the refill renewal request was postponed after review of the amount of medication on hand and the presence of an upcoming follow-up. Medication outcomes (ie, continued, dose changed, held, medication changed to a different oral anticancer medication, or discontinued) resulting from the follow-up were collected. Cost avoidance in US dollars was assigned based on the outcome of follow-up by calculating the price per unit times the number of units that would have been unused or in excess of what was needed if the medication had been dispensed before the scheduled follow-up. The average wholesale price minus 20% (AWP-20%) and wholesale acquisition cost (WAC) were used to report a range of costs avoided over 12 months. The total cost avoidance over 12 months associated with postponing refill renewal requests in a large academic health system with an integrated specialty pharmacy ranged from $549,187.03 using WAC pricing to $751,994.99 using AWP-20% pricing, with a median cost avoidance per fill of $366.04 (WAC) to $1,931.18 (AWP-20%). Refill renewal requests were postponed in 159 instances for 135 unique patients. After follow-up, medications were continued unchanged in only 2% of postponed renewals, 56% of follow-ups resulted in medication discontinuations, 32% in dose changes, 5% in medication changes, and 5% in medication holds. Integrated health system specialty pharmacist postponement of refill requests after review of the amount of medication on hand and upcoming follow-up proved effective in avoiding waste and unnecessary medication costs in patients treated with oral anticancer medications at a large academic health system.

Incorporating social determinants of health into patient care workflows within a health system specialty pharmacy

BackgroundThe influence of adverse factors on social determinants of health and their impact on patient outcomes is widely recognized. Pharmacists, as accessible healthcare professionals, can play a pivotal role in identifying and addressing SDOH concerns. Health system specialty pharmacies have consistently assisted patients in accessing expensive specialty medications and ensuring adherence to therapy. As such, they are uniquely positioned to address SDOH concerns of patients. ObjectiveTo assess the effectiveness of incorporating standardized SDOH screening and referral methods into the patient care workflows of a health-system specialty pharmacy. Practice descriptionThe University of North Carolina Health Care (UNC Health) Specialty and Home Delivery Pharmacy is a health-system owned specialty pharmacy serving patients in North Carolina, South Carolina, and Virginia. It holds accreditations from the Utilization Review Accreditation Commission and Accreditation Commission for Health Care. Practice innovationA standardized SDOH screening and referral method were integrated into patient care workflows of a health-system specialty pharmacy. If SDOH concerns were identified upon screening by a specialty pharmacist, patients were referred to an entity within the health system responsible for connecting patients to local community resources to address their SDOH concerns. Evaluation methodsThe types of SDOH concerns, frequency of SDOH referrals, referral turnaround time, outcomes of the referrals, and patient demographics were evaluated to determine the impact of this project. Descriptive statistics were used to analyze results. ResultsSixty-nine patients were included (female: n = 38, 55.1%; age (mean±SD: 48.9 ± 16.3). Eighty-seven SDOH concerns were reported, 54 patients (78.3%) were connected to local resources upon referral, and the average turnaround time of referrals was 2.2 business days. ConclusionThe findings of this pilot study highlight the effectiveness of incorporating SDOH screening and referral methods into specialty pharmacy workflows. Specialty pharmacies can successfully identify and address nonmedical factors impacting patients.

Comparison of time to treatment initiation of specialty medications between an integrated health system specialty pharmacy and external specialty pharmacies.

Specialty medications are commonly dispensed through specialty pharmacies equipped to meet unique monitoring and dispensing requirements. Integrated health system specialty pharmacies (HSSPs) coordinate with health system providers to deliver specialty medications to patients and ameliorate barriers to care. However, payors may restrict specialty medication fills to specialty pharmacies external to the health system, potentially leading to delayed treatment. To compare time to treatment initiation among patients whose specialty medications were transferred to external pharmacies and patients whose medications were filled at an internal HSSP. This was a retrospective, propensity-matched cohort study examining time to treatment initiation in patients with a specialty medication referral to the University of Kentucky HealthCare Specialty Pharmacy between July 1, 2021, and July 1, 2022. Patients were classified into cohorts by receipt of dispensing services from the internal HSSP or an external specialty pharmacy. Data collected via chart review included insurance type, reason for prescription transfer, dates of service (including prescription order, transfer, and receipt of medication), and whether a prior authorization or clinical intervention was performed. Subgroup analyses were performed for patients requiring a prior authorization or clinical intervention. The Wilcoxon signed-rank test was used to assess for statistically significant differences in time to treatment initiation between cohorts. A total of 560 patients with external transfers were identified for inclusion into the study, and after exclusion criteria were applied, 408 external transfer patients were propensity matched 1:1 to 408 patients with internal fills (total n = 816). Time to treatment initiation was significantly longer in the external transfer cohort as compared with the internal fill cohort, (18 days vs 12 days; P < 0.0001). The internal fill cohort had a greater mean days from provider order to the medication being ready to fill compared with the external transfer cohort (10 days vs 6 days; P < 0.0001). The internal fill cohort had fewer mean days from the medication being ready to fill to patient receipt of the medication as compared with the external transfer cohort (2 days vs 12 days; P < 0.0001). Similar findings were observed in the subgroup analyses. Average time to treatment initiation was 6 days shorter for patients whose specialty medications were filled at this HSSP compared with externally transferred patients. Delays in therapy can cause a negative impact on patient care and disease state management, with increased concern for specialty populations. The results of this study highlight the need for continued discussion about policies that limit patient choice to in-network pharmacies.

Impact of pharmacist-driven referral to increase specialty pharmacy prescription capture.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. To assess the impact of a clinical pharmacy specialist (CPS) embedded within a rheumatology clinic at a large academic medical center on the prescription capture rate at the health-system specialty pharmacy. Initially low prescription capture rates for the health-system specialty pharmacy led to the integration of a CPS in the main campus rheumatology clinic. Benchmarking was completed by assessing the prior prescription capture rate using electronic medical record analytics and Loopback Analytics (a database of prescription capture for the health-system specialty pharmacy). The existing workflows for both the rheumatology clinic and specialty pharmacy were observed with regard to biologic medication ordering and processing. Strategies for an updated workflow for biologic ordering with the incorporation of an embedded CPS in the rheumatology clinic were designed. This new workflow was established with key stakeholders, including the CPS, rheumatology providers, clinic staff, and pharmacy technicians. Once the workflow was established, all parties were educated and updated, including rheumatology providers, nursing staff, and specialty pharmacy staff. Prescription capture rate was monitored on a monthly basis. Prescription capture increased from 13.16% before pharmacist implementation (October to December 2021) to 35.42% after pharmacist implementation (October to December 2022) (P = 0.019). During the same periods, the revenue generated increased from $43,222.89 to $135,198.70 (P = 0.224) and the proportion of prescriptions initially sent to the health-system specialty pharmacy compared to other specialty pharmacies increased from 37% to 79% (P < 0.001) with CPS implementation. Expansion and implementation of pharmacy services by integrating a CPS in a rheumatology ambulatory clinic increased prescription capture and pharmacy revenue while optimizing patient care. We hope to expand similar CPS services to other clinics within the health system.

Optimal follow-up schedule for patients taking PCSK9 monoclonal antibodies in a health system: Analysis of specialty pharmacy clinical interventions.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The objective of this study was to determine if and when it is clinically appropriate to consider a reduction in the frequency of health-system specialty pharmacy (HSSP) clinical pharmacist assessments for patients taking a proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody (mAb) after they are deemed clinically stable on therapy. A single-center, retrospective, observational study of adult patients on PCSK9 mAb therapy enrolled in the University of Rochester Specialty Pharmacy Cardiology Patient Management Program was performed between October 24, 2016, and April 30, 2022. The primary outcome was the number of clinical pharmacist interventions per interval within the baseline 12 months compared to 12-month intervals for up to 72 months after initiation of PCSK9 mAb therapy. A total of 368 patients on PCSK9 mAb therapy were included in the study. A significantly lower percentage of patients had more than 2 interventions during the 12- to 24-month interval (24.3%) as compared to the baseline 12-month interval (80.2%) (P < 0.001); this represented a 70% reduction in the chance of a patient requiring more than 2 interventions (relative risk, 0.30; 95% CI, 0.24-0.38). A similar trend was demonstrated in the 24- to 36-month and 36- to 48-month intervals when compared to the first year of therapy. The most commonly documented clinical pharmacist interventions were the categories of safety (29.2%), effectiveness (28.4%), and adherence (19.9%). Patients beyond 1 year of PCSK9 mAb therapy required less clinical pharmacist interventions. Therefore, stable patients receiving a PCSK9 mAb may be considered for less frequent clinical assessments to allow for HSSP growth to nontraditional clinical areas.

Biosimilar perceptions among autoimmune prescribers and pharmacists in health system specialty pharmacy.

By the end of 2023, 10 self-administered biosimilars indicated for autoimmune conditions are expected to launch in the United States, resulting in alternative treatment options for patients and a potential for cost savings. However, studies about perception and knowledge of self-administered biosimilars among health system prescribers and health system specialty pharmacists are limited. To assesses knowledge and perceptions of biosimilars among autoimmune prescribers and health system specialty pharmacists across the United States. An anonymous, cross-sectional self-administered online questionnaire was conducted among prescribers and health system specialty pharmacists practicing in the specialties of rheumatology, dermatology, and gastroenterology across the United States. The survey was available from January 2023 to February 2023. 31 prescribers and 44 pharmacists completed the questionnaire. Only 16.0% of prescribers and 13.4% of pharmacists reported being "very prepared" to have conversations with patients about biosimilar options. 43% of prescribers indicated they would prescribe a biosimilar to biologic naive patients. However, 13.3% of prescribers would be willing to prescribe a biosimilar to patients successfully established on biologic therapy. Among pharmacists, 68.1% were comfortable recommending a biosimilar substitution to a biologic naive patient, but only 18.1% would recommend a biosimilar substitution to an existing patient successfully established on a biologic therapy. Less than half of prescribers (48.0%) and pharmacists (42.0%) understood regulations of interchangeability and substitution. Our study highlights several knowledge gaps and hesitancies that exist among health system specialty prescribers and pharmacists regarding biosimilar products. Education efforts are needed to overcome the lack of biosimilar adoption, which will increase affordability of therapy for patients and health care savings.

Role of an embedded health system specialty pharmacy on prescription of biologics in allergy/immunology

Role of an embedded health system specialty pharmacy on prescription of biologics in allergy/immunology

Health-system specialty pharmacist intervention types, acceptance, and associated actions for patients with multiple sclerosis.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Health-system specialty pharmacy (HSSP) pharmacists play an integral role in the care of patients with multiple sclerosis (PwMS) by facilitating medication access, providing counseling, improving adherence, and decreasing provider workload. However, current literature detailing pharmacist interventions and their acceptance rates in this population is limited. The purpose of this study was to identify the types and acceptance rate of clinical interventions completed by pharmacists for PwMS. To evaluate the acceptance rate of HSSP pharmacist interventions, we conducted a retrospective, multicenter, observational, descriptive study for the period from October 2019 to August 2022. Intervention types were categorized into reasons for intervention, recommendations from the pharmacists, and their acceptance rates. For 225 patients enrolled in HSSP services, 449 interventions were completed with an average of 2.0 interventions per patient. Most interventions identified were associated with medication adherence (28.7%), medication regimen (27.6%), adverse drug reaction (ADR) (20.7%), and laboratory values (15.1%). The average adherence, defined by the proportion of days covered, was 94%. The most common recommendations were to continue therapy (14.9%), schedule laboratory tests (12.7%), and follow up with providers (11.8%). Recommendations had an acceptance rate of 85.3%, with 3.8% of recommendations declined and 10.9% requiring follow-up with providers. P Pharmacists impact patient outcomes through the completion of clinical interventions that improve adherence, identify medication regimen problems, manage ADRs, and coordinate proper laboratory testing. Pharmacist recommendations were most often accepted for interventions related to medication regimen and ADRs. Proper identification and management of medication regimen concerns, as well as tolerability of medications, can positively impact adherence and improve overall patient outcomes.

Evaluation of the impact of a health-system specialty pharmacy patient management program on achieving predefined clinical outcome measures.

Specialty medications often have high costs, pose difficulties with payor approval, and require additional monitoring. Earlier articles have defined various examples of clinical outcome measures (COMs); however, goals and benchmarks have not been well defined, and a gap in the literature exists. This study evaluated the effectiveness of our health-system specialty pharmacy (HSSP) patient management program (PMP) in achieving predefined COM goals. Disease state protocols were developed within the HSSP, and clinical and adherence goals were created for each COM based on primary literature. This retrospective, single-center review examined outcomes and adherence data on patients enrolled in the PMP during 2022. The primary outcome was the number of predefined disease state COM goals met. Secondary outcomes included the number of predefined adherence goals met and annual financial impact. Of 1,431 patients whose records were reviewed, 1,053 met criteria for inclusion. The primary outcome analysis showed that 85% (33 of 39) of the predefined disease state goals were met. Predefined adherence goals were met, with an average proportion of days covered (PDC) for all specialty medications of >90%. The PMP yielded $5,167,043 in direct patient cost savings and $167,260 in cost avoidance. The PMP yielded positive results in meeting goals set for the COMs in the disease states managed within the HSSP. COMs will remain a focus for HSSPs to help patients achieve desired clinical outcomes and HSSPs adhere to accreditation standards. More research in this field and standardization of COM goals may benefit the larger HSSP community.

1577. HIV Viral Load Suppression in Patients Utilizing an Integrated Health System Specialty Pharmacy Compared to a Non-integrated Specialty Pharmacy Model

Abstract Background Patients with HIV who adhere to antiretroviral (ARV) therapy can achieve and maintain viral suppression (defined as &amp;lt; 200 copies of HIV/mL). Integrated Health System Specialty Pharmacies (HSSPs) help patients overcome barriers to ARV adherence, but there are limited data on the impact of HSSPs on clinical outcomes. This study compared viral suppression for patients filling ARVs at UMass Memorial Specialty Pharmacy to those utilizing a non-integrated specialty pharmacy (non-HSSP). Methods In this retrospective cohort study, patients aged ≥18 years with an HIV diagnosis, encounter at the UMass Memorial Medical HIV Clinic, an ARV medication order, and at least one viral load (VL) result between January 2018 and May 2022 were identified from the medical record. Data included: age, sex, race, ethnicity, comorbidities, and all VL results over the study period. Time of first HSSP fill date was used to identify patient start in the respective pharmacy. VL results were divided into time under HSSP or non-HSSP (Figure 1). The index time was first VL for patients in either the HSSP or non-HSSP group. To account for multiple VL measures per patient, a Generalized Estimating Equation logistic regression estimated odds ratios (OR) and a 95% confidence interval. An OR &amp;gt;1 indicates greater viral suppression. Viral load (VL) lab results were collected while patients were in Integrated Health System Specialty Pharmacies (HSSP) or Non-Integrated Specialty Pharmacy (Non-HSSP). Index time (time=0) is firts VL result while in HSSP or Non-HSSP. Examples of 3 patients timelines, each represents a lab result. Results Of the 889 patients identified, 326 provided VL results under HSSP while 681 contributed results for non-HSSP; 118 patients provided results for both groups (Figure 2). Of the 5,295 VL results, 2,028 were from HSSP patients and 3,267 from the non-HSSP group. Of the 5,295 total VLs, 90.6% indicated viral suppression, with the average rate of 91.0% in the HSSP group vs 86.0% in the non-HSSP group. Table 1 displays unadjusted and adjusted ORs estimates. The HSSP group had a higher rate of viral suppression (adjusted OR = 1.89 95% CI: [1.40, 2.56]). Sex, ethnicity, and race were not significantly associated with viral suppression, which decreased with Charlson Comorbidity Index (CCI) 1-3; increased with age; and increased over time (from index date of VL). Conclusion Among patients evaluated at UMass Memorial HIV Clinic, those filling ARV medications at the HSSP demonstrated higher rates of viral suppression compared to patients utilizing a non-HSSP. Disclosures Karen I. Salomon-Escoto, MD, Novartis: clinical trial PI Jonathan Kay, MD, Aker BioMarine AS: Grant/Research Support|Alvotech Swiss AG: Advisor/Consultant|Boehringer Ingelheim GmbH: Advisor/Consultant|Bristol Myers Squibb Co.: Advisor/Consultant|Fresenius Kabi: Advisor/Consultant|Galapagos NV: Grant/Research Support|Inmagene LLC: Independent Data Monitoring Committee member|Kolon TissueGene, Inc.: Independent Data Monitoring Committee member|Novartis Pharmaceuticals Corp.: Advisor/Consultant|Organon LLC: Advisor/Consultant|Pfizer Inc.: Advisor/Consultant|Samsung Bioepis: Advisor/Consultant|Sandoz Inc.: Advisor/Consultant|Scipher Medicine: Advisor/Consultant|Teijin Pharma Ltd.: Advisor/Consultant|Wolters Kluwer NV: Royalties for UpToDate

376 Impact of total care pharmacy services provided by a health system specialty pharmacy on long-term medication adherence in peoplewith cystic fibrosis

376 Impact of total care pharmacy services provided by a health system specialty pharmacy on long-term medication adherence in peoplewith cystic fibrosis

A descriptive survey of specialty pharmacy team members' perceptions of interactions with field representatives from pharmaceutical companies.

BACKGROUND: It is not well understood in literature what the time spent between health care professionals, including pharmacists and pharmacy technicians, and pharmaceutical field specialists equates to in terms of changes in productivity or lost time, the educational value provided, or the nature of the resources provided in terms of improving patient care. OBJECTIVE: To evaluate the volume of, and time spent in, pharmaceutical field representative (PFR) meetings by members of an integrated specialty pharmacy team at a large academic medical center. METHODS: A 16-item survey tool used skip and branching logic comprising binary, multiple-choice, multiple-select, and open-ended items was distributed to pharmacists and pharmacy technicians at a health-system specialty pharmacy on the south side of Chicago, Illinois. The survey assessed locations of interactions with PFR, who initiated the request, reason for interaction, time spent, whether the participant felt the interaction provided value, and whether it contributed to them working a longer shift or compromising time spent on patient care that day. RESULTS: There were a total of 108 responses. Of those, 44 responses documented having an interaction with a PFR, and the remaining responses indicated no interaction that week. Only 5 (11.4%) of the interactions were pharmacy team member initiated. Among the pharmacy team member-initiated meetings, all respondents stated that the interaction had provided value, and none reported that it led to a longer workday. Conversely, of the 36 pharmaceutical representative-initiated interactions, 15 (41.6%) found value and 5 (13.8%) said that their workday was elongated because of these interactions. CONCLUSIONS: Our findings demonstrate that the majority of encounters taking place between our specialty pharmacy team members and PFRs did not result in knowledge gained or provision of tools and resources to support our patients. The next steps include 3 specific proposed changes to how our team responds to meeting requests from PFRs, specifically aimed at reducing pipeline presentations, reducing meetings pertaining to limited distribution drugs not accessible to the specialty pharmacy, and reducing meetings with the intent of introduction or pass off of contacts between PFRs.

ASHP Survey of Health-System Specialty Pharmacy Practice: Practice Models, Operations, and Workforce - 2022.

The results of the 2022 American Society of Health-System Pharmacists (ASHP) Survey of Health-System Specialty Pharmacy (HSSP) Practice: Practice Models, Operations, and Workforce are presented. A total of 273 leaders in HSSPs were contacted by email to complete a survey hosted using Qualtrics. The survey sample was compiled from ASHP member lists, the presence of a specialty pharmacy indicated in previous ASHP surveys, and outreach to ASHP member organizational leaders. The survey response rate was 35.9%. Most HSSPs dispense 30,000 or fewer specialty prescriptions annually. Most respondents have an annual revenue of $100 million or less, are part of a 340B-covered entity, operate one location, have 1 to 2 specialty pharmacy accreditations, dispense both nonspecialty and specialty medications, and employ an average of 15.5 pharmacists and 17.6 technicians. The majority (66.7%) dispense 50% or less of prescriptions written by internal providers due to payor and manufacturer network restrictions. Over one-third employ nonpharmacist and nontechnician professionals. Specialty pharmacists are involved in treatment decisions and therapy selection before prescription generation (69.8%), and 47.7% of respondents report pharmacists operating under collaborative practice agreements. Most (82.6%) offer experiential or formal education in specialty pharmacy. The top point of pride remains patient satisfaction and level of service. Top challenges include access to payor networks, the ability to hire and retain qualified staff, and shrinking reimbursement from payors. The HSSP is a continually maturing integrated advanced practice model focused on providing patient-centric care to all patients and employees of the health system regardless of network status. HSSPs are raising the standards for quality in specialty pharmacy care.

Provision of ambrisentan from a health-system specialty pharmacy affiliated with a pulmonary hypertension Center of Comprehensive Care.

This descriptive report describes the process used to obtain access to providing ambrisentan from a health-system specialty pharmacy (HSSP) affiliated with a pulmonary hypertension Center of Comprehensive Care, develop a pulmonary arterial hypertension (PAH) care team at the HSSP, and characterize medication adherence and access metrics. PAH is a rare disease treated with several specialty medications requiring intensive monitoring. Historically, specialty medications used to treat PAH have been provided by only select specialty pharmacies due to restricted drug distribution channels. It is recommended that patients with PAH receive their care at centers with expertise in the diagnosis and management of this disorder, but the HSSPs at these expert centers are unable to provide specialty PAH medications. The current care model for PAH leads to patients receiving their medical and pharmaceutical care from separate entities. This descriptive report describes a multidisciplinary team's approach to gaining access to providing ambrisentan and developing a disease state care team within an established HSSP. After implementing this service, specialty pharmacy metrics were assessed, including proportion of days covered (PDC), time to first fill, patient contact rate, Risk Evaluation and Mitigation Strategy (REMS) program compliance, time to prior authorization (PA) approval, rate of optimal adherence (PDC of >80%), and PA renewal rate, to demonstrate a proof-of-concept HSSP model for PAH. In this model, the HSSP was able to demonstrate high-quality specialty pharmacy metrics with regard to medication adherence, medication access, and REMS program compliance. The development of a PAH care team to provide ambrisentan at an existing HSSP was associated with high adherence rates, efficient and reliable medication access, and REMS program compliance.

Primary medication nonadherence rates to specialty disease-modifying antirheumatic drugs for rheumatoid arthritis within a health system specialty pharmacy.

BACKGROUND: Assessing primary medication nonadherence, the rate at which a medication is prescribed for a patient but is not obtained or replaced with an alternative medication within a reasonable time period, can provide a better understanding of the frequency and impact of these barriers to medication access. Previous literature has reported high rates of primary medication nonadherence, ranging from approximately 20% to 55% in patients with rheumatoid arthritis (RA) treated with specialty disease-modifying antirheumatic drugs (DMARDs). The high primary medication nonadherence rate may reflect the difficulties associated with obtaining specialty medications, such as high costs, extended prior authorizations, and pretreatment safety requirements. OBJECTIVE: To evaluate reasons for and rates of primary medication nonadherence to specialty DMARDs in patients with RA referred to an integrated health systems specialty pharmacy. METHODS: We conducted a retrospective cohort study examining eligible patients with a specialty DMARD referral from a health system rheumatology provider to the health system specialty pharmacy. Initially, pharmacy claims were used to identify primary medication nonadherence, defined as the lack of a fill event within 60 days following the medication referral for patients without a specialty DMARD claim in the 180 days prior. Referrals from July 1, 2020, to July 1, 2021, were eligible. Exclusion criteria included duplicate referrals, use for non-RA indications, switches to clinic-administered therapies, and alternate filling methods. Medical record reviews were conducted to confirm referral outcomes. Outcomes included rate of and reasons for primary medication nonadherence. RESULTS: We included 480 eligible patients, 100 of whom had no documented fill event. After medical record review, 27 patients were removed due to having a non-RA diagnosis and 65 patients were removed due to having alternative fill methods, most due to external prescription routing (83.1%). The final primary medication nonadherence rate was 2.1%. Out of the 8 cases of true primary medication nonadherence, 3 patients held specialty DMARD therapy because of other existing disease states, 3 patients were unreachable, and 2 patients were unable to afford medication. CONCLUSIONS: Rates of primary medication nonadherence to specialty DMARDs were low in patients with RA managed by a health system specialty pharmacy. A total of 8 primary medication nonadherence cases were related to safety concerns in non-RA diseases states, patient unreachability, and affordability. However, the limited number of primary medication nonadherence cases limits the generalizability of reasons for primary medication nonadherence found in this study. Key elements of the health systems specialty pharmacy model that likely contribute to low primary medication nonadherence include dedicated financial assistance navigation services, in-clinic pharmacist availability, and open communication between provider offices.

Health-system specialty pharmacy services: Setting the standard.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Development of a framework to support data-driven decision-making in a health-system specialty pharmacy.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Optimizing HIV PrEP Persistence: Does Your Pharmacy Matter?

Persistence to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is integral to preventing new HIV infections. Previous studies have shown real-world PrEP persistence is low and insight is needed into PrEP delivery strategies that improve persistence. This single-center, retrospective, cohort study measured persistence in patients filling PrEP through an integrated health-system specialty pharmacy (HSSP) compared to those filling at external pharmacies. The Kaplan-Meier estimates for persistence probability at 6, 12, and 18 months were 0.87 (95% CI 0.79-0.95), 0.75 (95% CI 0.66-0.86), and 0.64 (95% CI 0.53-0.76) for the HSSP cohort compared to 0.65 (95% CI 0.51-0.83), 0.41 (95% CI 0.28-0.62), and 0.32 (95% CI 0.2-0.53), respectively, for the non-HSSP cohort (log-rank p < 0.001, [Formula: see text] = 11.2). Cox PH modeling showed that patients using a non-HSSP were 2.7 times more likely to be non-persistent than HSSP patients (HR 2.7, 95% CI 1.6-4.7, p < 0.001, [Formula: see text] = 12.61), demonstrating patients were better maintained on PrEP therapy when their prescriptions were filled with the HSSP.