Use Of Essential Medications Research Articles

Use of Essential Medicines for Pain Relief and Palliative Care: A Global Consensus Process

ContextThe WHO Model List of Essential Medicines includes 24 medications under the section Medicines for Pain and Palliative Care (EML). The Lancet Commission on Pain and Palliative Care developed the Lancet Essential Package (LEP), including 35 medications designed to alleviate serious health-related suffering worldwide. ObjectivesThis study aims to provide recommendations on the appropriate use of essential of medicines in palliative care. MethodsThe global palliative care community was invited to submit guidelines, of which 19/22 were selected. Data was extracted on initial dose, frequency, and maximum daily dose for medications in the LEP and in the WHO EML. For medications where guidance was not available or information differed, a 2-round Delphi process was conducted with 70 experts across regions and income levels. Consensus was set to ≥70% agreement. ResultsConsensus in the guidelines was identified for 24 medications on three parameters. Open questions (mostly on maximum daily dose) were included in the Delphi. 63 experts from 49 countries responded (RR = 90%). No consensus was achieved for the maximum daily dose for nine medications. Significant disparities in medication availability were noted between high-income and low/middle-income countries. ConclusionWe were able to partly achieve our goal, with limited evidence and a wide range of clinical practice described by the experts. This highlights an important gap in critical information which affects mostly the provision of palliative care at the primary care. Both limited availability and lack of training on the adequate use of essential medications may affect how clinicians manage symptoms, possibly relying on personal experience or trial and error, rather than evidence-based information.

PCV65 - The Impact of a Value-Based Insurance Design for Chronic Preventive Medications on Adherence and Persistence in an Integrated Delivery System

To evaluate the effect of reduced copays on medication adherence rates for specific chronic and preventive medications (e.g. diabetes, respiratory diseases, anticoagulation) in an integrated delivery system (IDS). Patients with age > 18 and at least one pharmacy claim for selected chronic and preventive medications between April 1, 2015 and March 31, 2017 were eligible. Medication adherence was measured by estimating the number of days of medication available to each patient or the “proportion of days covered” (PDC) every 3 months for 12 months before and after the copay reduction program implementation on April 1, 2016. The analysis included a repeated measure analysis of variance to assess the trends before and after the intervention date to estimate the interaction between the intervention, trend, medication class, and other variables of interest. T tests compared the mean change in post-period versus pre-period adherence within groups. This study used existing plan pharmacy claims, medical claims, and electronic medical record (EMR) data from commercially insured patients in the IDS. A total of 10 drug classes from 3 therapeutic areas were observed. Post-period average quarterly PDCs increased 5% from the pre-period (t=5.1, 59% vs 54%, p<.0001). Diabetes (76% vs 71%), respiratory diseases (48% vs 44%), and anticoagulation (71% vs 69%) all showed an increase in average PDC in the post-intervention period. The regression model supported the effect of the value-based insurance program on increasing adherence after the intervention (p<.0001). This policy produced an intended effect. We observed an increase in overall adherence across all drug classes after implementation of the value-based insurance program. This study supports the ability of copay reductions to increase the use of essential medications and improve clinical outcomes without increasing overall health spending.

Medicaid prescription limits: policy trends and comparative impact on utilization.

BackgroundMedicaid programs face growing pressure to control spending. Despite evidence of clinical harms, states continue to impose policies limiting the number of reimbursable prescriptions (caps). We examined the recent use of prescription caps by Medicaid programs and the impact of policy implementation on prescription utilization.MethodsWe identified Medicaid cap policies from 2001–2010. We classified caps as applying to all prescriptions (overall caps) or only branded prescriptions (brand caps). Using state-level, aggregate prescription data, we developed interrupted time-series analyses to evaluate the impact of implementing overall caps and brand caps in a subset of states with data available before and after cap initiation. For overall caps, we examined the use of essential medications, which were classified as preventive or as providing symptomatic benefit. For brand caps, we examined the use of all branded drugs as well as branded and generic medications among classes with available generic replacements.ResultsThe number of states with caps increased from 12 in 2001 to 20 in 2010. Overall cap implementation (n = 3) led to a 0.52 % (p < 0.001) annual decrease in the proportion of essential prescriptions but no change in cost. For preventive essential medications, overall caps led to a 1.12 % (p = 0.001) annual decrease in prescriptions (246,000 prescriptions annually) and a 1.20 % (p < 0.001) decrease in spending (−$12.2 million annually), but no decrease in symptomatic essential medication use. Brand cap implementation (n = 6) led to an immediate 2.29 % (p = 0.16) decrease in branded prescriptions and 1.26 % (p = 0.025) decrease in spending. For medication classes with generic replacements, the decrease in branded prescriptions (0.74 %, p = 0.003) approximately equaled the increase in generics (0.79 %, p = 0.009), with estimated savings of $17.4 million.ConclusionsAn increasing number of states are using prescription caps, with mixed results. Overall caps decreased the use of preventive but not symptomatic essential medications, suggesting that patients assign higher priority to agents providing symptomatic benefit when faced with reimbursement limits. Among medications with generic replacements, brand caps shifted usage from branded drugs to generics, with considerable savings. Future research should analyze the patient-level impact of these policies to measure clinical outcomes associated with these changes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1258-0) contains supplementary material, which is available to authorized users.

Trends in the utilization of antihypertensive medications among Palestine refugees in Jordan, 2008-2012

ObjectivesThe purpose of this study is to describe trends in the utilization of antihypertensive medications, overall and by type of medication, specifically thiazide diuretics, as well as uncontrolled hypertension, in the Palestine refugee population in Jordan between 2008 and 2012.MethodsWe analyzed aggregate procurement data on antihypertensive medications derived from the United Nations Relief and Works Agency (UNRWA) pharmacy records between 2008 and 2012. Antihypertensive medications were aggregated and utilization was calculated overall and for specific types of antihypertensive medications (e.g. β-blockers, diuretics). We used the WHO (World Health Organization) defined daily dose (DDD) methodology, often used to evaluate drug utilization patterns using aggregate data, to calculate utilization defined as DDDs per 100 persons with hypertension. In addition, UNRWA medical records were used to measure the prevalence of uncontrolled hypertension in the primary care setting. Uncontrolled hypertension was defined as a systolic/diastolic blood pressure ≥140/90 in at least 2 out of 3 readings, one of which is the most recent reading, during the year for a patient diagnosed with hypertension.ResultsOverall, total utilization of antihypertensive medications has not changed between 2008 and 2012; hypertensive patients persistently used at least 2 antihypertensive medications daily (range 200–280 DDDs/100 patients with hypertension) during this five-year period. However, there is significant variation in utilization patterns by type of antihypertensive medication. While Angiotensin Converting Enzyme Inhibitors (ACE-I) were persistently the most commonly used antihypertensive medication, there utilization significantly (P < 0.05) declined by 26%. However, there was a statistically significant increase of 124% in the utilization of thiazide diuretics. Further, the prevalence of uncontrolled hypertension has also declined at a rate of 3% annually between 2008 and 2012.ConclusionOur findings indicate that the STGs for hypertension management implemented in 2009 as part of UNRWA's essential drug program have increased the utilization of thiazide diuretics, and potentially contributed to improvements in hypertension control. This study also demonstrates that feasibility of drug utilization studies in monitoring and evaluating trends in the use of essential medications in low-resource settings.

Medicare Part D's Effect on the Under‐ and Overuse of Medications: A Systematic Review

To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes. Systematic review. Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010. Medicare beneficiaries who obtained drug insurance from the Part D program. The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles. Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined. Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.

Surgical Mortality, Hospital Quality, and Small Sample Size

In Reply: We strongly endorse the use of direct generic substitution and “rational prescribing” when they are based on rigorous scientific information, because these are important ways to help people manage their drug expenditures. This is based on our own finding that seniors who exceeded their drug benefit caps decreased their use of essential medications, as well as on estimates from others that 1 in 4 Medicare beneficiaries will face the “donut hole” in the new Medicare drug benefit. This “donut hole” represents the gap in coverage when beneficiaries’ annual drug expenditures exceed their benefit cap but are not yet high enough to qualify for catastrophic coverage. Better mechanisms to help people manage their drug costs must be found. We thank Drs Bjarnason and Kampmann for highlighting these programs in Denmark. Currently, all 50 states in the United States allow pharmacists to make direct generic substitutions unless directly prohibited by clinicians on the prescription. We support the additional development of evidence-based guidelines that take into account cost as well as safety and effectiveness to help clinicians and patients choose medications. However, transparency to both the patient and the clinician regarding potential cost-effectiveness trade-offs is essential. In the United States, health plans, insurers, and pharmacy benefit managers often send information to clinicians and patients to increase their awareness of drug costs and effectiveness. Other sources such as the treatment guidelines from The Medical Letter on Drugs and Therapeutics and from the State of Oregon have also added cost information to independent comparisons of drug effectiveness and safety. Further work is needed to ensure consistency among these guides and to help patients and clinicians use these tools in daily practice so that a patient’s health is optimized at the price that he or she is willing to pay.

Cost-lowering strategies used by medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage.

The majority of Medicare drug benefits in managed care (Medicare + Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage. To describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden. A survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month. Proportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions. In multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P<.001), but similar proportions reported stopping medications completely (8% for both, P =.86) and of not starting prescribed medications (6% vs 5%, P =.39). Patients exceeding caps more often called pharmacies to find the best price (46% vs 29%, P<.001), switched medications (15% vs 9%, P =.002), used samples (34% vs 27%, P =.006), and had difficulty paying for prescriptions (62% vs 37%, P<.001). Twelve of the 20 therapeutic classes most often affected by decreases in use of medication were for chronic health problems such as hypertension, hyperlipidemia, and emphysema or asthma. Medicare beneficiaries often decreased use of essential medications and experienced difficulty paying for prescriptions during gaps in coverage. Health professionals need to explore how they can lessen the impact of caps on patients' health and financial burden.

Utilization of essential medications by vulnerable older people after a drug benefit cap: importance of mental disorders, chronic pain, and practice setting.

To identify specific characteristics of patients, physicians, and treatment settings associated with decreased receipt of essential medications in a chronically ill, older population following a Medicaid three-prescription monthly reimbursement limit (cap). Quasi-experiment with bivariate and multivariate regression. Patients in the New Hampshire Medicaid program and their regular prescribing physicians. Three hundred and forty-three chronically ill Medicaid enrollees with regular use of essential medications for heart disease, asthma/chronic obstructive pulmonary disease, diabetes mellitus, seizure, or coagulation disorders who received an average of three or more prescriptions per month during the baseline year. Postcap patient-level change in standard monthly dose of essential medications compared with the baseline period, presence of 11 comorbidities (defined by regular use of specific indicator drugs), practice setting, and location of regular prescribing physician. The mean percentage change in standard doses of essential medications following the cap was -34.4%. Larger changes were significantly associated with several baseline measures: greater numbers of precap medications, greater numbers of comorbidities, longer hospitalizations, and greater use of ambulatory services. The three comorbidities associated with the largest relative reduction in essential drug use were psychoses/bipolar disorders, anxiety/sleep problems, and chronic pain. Patients of physicians in group practices, clinics, or hospitals tended to have smaller dose reductions than those whose physicians were in solo or small-group practice. Patients most at risk of reduced access to essential medications because of a reimbursement cap include those with multiple chronic illnesses requiring drug therapy, especially illnesses with a mental health component. Physicians in clinics or large group practices may have maintained patient medication regimens more effectively.