Publications

BACKGROUND: Prescribing rates and adherence to evidence-based cardiometabolic medications remain suboptimal. Many strategies to improve prescribing and adherence have been developed, among which pharmacy care management (PCM) programs are among the most consistently effective. Data on PCM programs come from studies that developed interventions specifically for research purposes. Benefits of real-world PCM programs for patients with cardiometabolic conditions are incompletely understood.

OBJECTIVE: To evaluate the effect of an existing PCM program in individuals with cardiometabolic conditions, specifically, whether the program improved adherence to cardiometabolic medications and reduced all-cause and cardiometabolic-specific health care use and whether those nonadherent at baseline would benefit most.

METHODS: We conducted a retrospective cohort study using adjudicated administrative claims data from a large regional Medicare Advantage Prescription Drug health plan. A total of 27,910 beneficiaries were identified as potentially eligible for the PCM program between December 2019 and November 2021. The cohort was restricted to individuals who filled at least 2 prescriptions for a cardiometabolic condition, filled at least 1 prescription after PCM enrollment, and were continuously eligible for health plan benefits for at least 12 months before and after enrollment. Potential controls met the same criteria but did not participate in the PCM program and filled prescriptions at non-PCM pharmacies. Control and PCM patients were matched 5:1 using direct and propensity score matching. The primary outcome was all-cause hospitalization over 12 months. Secondary outcomes included cardiometabolic medication adherence and disease-specific hospitalizations. We further evaluated program effects on rates of disease-specific hospitalization in patients nonadherent vs adherent at baseline.

RESULTS: 632 PCM patients were matched to 3,160 controls. PCM program participants had significantly greater improvements in adherence to all cardiometabolic medication classes, with difference-in-difference estimates ranging from 4.7% (P = 0.028) for anticoagulants to 17.0% (P < 0.001) for beta blockers. PCM program participants had 15% less all-cause hospitalizations per 1,000 patient months (P = 0.037) and experienced significantly fewer cardiometabolic-specific admissions (-33.7%; P = 0.025) and nonsignificant reductions in noncardiometabolic admissions (-8.4%; P = 0.201). PCM patients nonadherent at baseline had a significant 39.1% reduction in cardiometabolic hospitalizations (P = 0.003), whereas adherent patients had a nonsignificant 24.7% reduction (P = 0.286).

CONCLUSIONS: Compared with well-matched controls, PCM patients with cardiometabolic disease had significantly higher rates of medication adherence and significantly lower hospitalization rates during the 12-month follow-up period. This effect was greatest in patients nonadherent at baseline. Our results provide insights into how PCM programs achieve their benefits and underscore the value of targeting the PCM program to high-risk individuals.

Clostridioides difficile infection (CDI) guidelines advise against repeat testing within 7 days. This retrospective study identified factors associated with 7-day repeat testing. Attending physicians (aOR = 0.67) and advanced practice practitioners (aOR = 0.61) ordered fewer repeat tests compared to residents. Further research is necessary to address inappropriate repeat testing.

BACKGROUND: High-risk medications such as opioids and benzodiazepines are frequently prescribed in pediatric dental care, yet their prescribing patterns and associated adverse outcomes remain poorly understood. The aim of this study was to determine the extent of such prescribing to pediatric patients and factors associated with adverse outcomes.

METHODS: MarketScan data for patients younger than 18 years with a dental visit from 2014 through 2019 were analyzed. High-risk medications included benzodiazepines, barbiturates, and opioids. Composite outcomes included hospitalization, emergency department visit, or urgent care visit within 7 days after the dental visit. Opioid-attributable outcomes included opioid-related overdose within 7 days or persistent opioid use 4 through 365 days after the visit. Generalized estimating equations assessed the association between outcomes and patient and visit characteristics.

RESULTS: Among pediatric dental visits, 0.72% (n = 269,991) involved high-risk medications, with 4.3% experiencing a composite outcome. Higher odds were observed in ages 9 through 11 years (odds ratio [OR], 1.56), male patients (OR, 1.05), patients with complex chronic conditions (OR, 2.22), and care delivered in hospital or ambulatory surgery settings (OR, 2.20). Among dental visits with opioids, 10.1% had an opioid-attributable outcome, with the highest odds in patients 4 through 5 years (OR, 1.48), female patients (OR, 1.08), patients with complex chronic conditions (OR, 1.22), and care delivered in outpatient clinics (OR, 1.43).

CONCLUSIONS: One in 10 pediatric dental visits involving opioids was associated with opioid-related overdose or persistent use, with the highest odds in young children. These results highlight the need for caution in opioid prescribing and providing guideline-based nonopioid analgesia to children.

PRACTICAL IMPLICATIONS: Promote safer, equitable pediatric dental prescribing through guideline adherence, nonopioid pain management, and provider training.

Benzodiazepines are potentially inappropriate medications for older adults, and deprescribing interventions are needed. We describe the development of a psychologist-led, mindfulness-informed cognitive-behavioural therapy (CBT) intervention to pair with pharmacist-led tapering to support benzodiazepine deprescribing in older adults. Based on previous research, we first developed an intervention conceptual model. The aim of this study was to (1) gather stakeholder feedback on previous experiences with benzodiazepine tapering and on our intervention model and proposed intervention, and (2) integrate this qualitative feedback to develop an intervention manual. We conducted (a) semistructured individual interviews with older adults (N = 8) who previously attempted to taper their benzodiazepines, and (b) a focus group with members (N = 5) from a national deprescribing patient stakeholder group. Overlapping themes emerged, including support for the mindfulness-informed CBT intervention, the importance of control over taper pace, the need for a goal- and skills-oriented intervention, the importance of normalizing side effects of the taper and building confidence to manage side effects and the utility of fostering acceptance during the taper. These findings informed the development of a final intervention manual, named Confidence-Building Strategies for Reducing Sedative Medications (CSTARS), to be tested in a single-arm pilot feasibility trial.

BACKGROUND: Documentation of patient goals and preferences within medical records has the potential to align medication use with goals of care (GoC) and individualize medication appropriateness criteria. We characterized patient and surrogate-expressed GoC for older Veterans living with dementia and explored concordance with medication use during VA Community Living Center (CLC) (i.e., nursing home) stays.

METHODS: We conducted a cross-sectional analysis using the VA Residential History File, Minimum Data Set, Corporate Data Warehouse, and Medicare claims for Veterans with dementia admitted to VA CLCs from 4/2021 to 12/2021 for > 7 days. We extracted free text responses for "Veteran goals in own words" from a standardized GoC note. Two coders classified GoC topics using iterative coding. We examined bar code medication administration data for aspirin, benzodiazepines, opioids and antidementia medications within the 7 days following admission. We determined a schema for potential goal-concordant medication use (e.g., opioids for GoC focused on comfort) and assessed concordance of medication use with GoC topics.

RESULTS: Among 1000 VA CLC residents with dementia and GoC documented, 46.4% of responses were reported by the Veteran versus a surrogate. Common topics included comfort (44.6%), life-sustaining treatments (31.8%), function (13.7%), care setting/transitions (12.9%), and life prolongation (11.2%). Medications were seldom discussed. Opioid and benzodiazepine use was classified as goal-concordant for 56.7% and 72.2% of patients who used them. Aspirin and antidementia medication use was more commonly classified as goal-discordant (54.7% and 38.7%, respectively).

CONCLUSIONS: Goals elicited via an open-ended question provided only indirect information relevant to medication use, but in many cases could be used to refine judgments of appropriateness. Integration of patient goals into formal criteria evaluating medication appropriateness is a logical next step for medication optimization research. Future research should explore the utility of questions specific to medications in GoC conversations for individuals with dementia.

BACKGROUND: The Veterans Health Administration (VHA) launched VA Bug Alert (VABA) to identify admitted patients who are infected or colonized with multidrug-resistant organisms (MDROs) in real time and promote timely infection prevention measures. However, initial VABA adoption was suboptimal. The objective of this project was to compare the effectiveness of standard vs. enhanced implementation strategies for improving VABA adoption.

METHODS: 121 VA healthcare facilities were evaluated for adoption of VABA (at least 1 user registered at a facility) April 2021-September 2022. All facilities initially received standard implementation, which included: VABA revisions based on end-user feedback, education, and internal facilitation via monthly meetings with the MDRO Prevention Division of the VHA National Infectious Diseases Service. Surveys evaluated VABA perspectives among MDRO Prevention Coordinators (MPCs) and/or Infection Preventionists (IPs) before and after initial standard implementation. Facilities not registered for VABA following initial standard implementation (n = 31) were cluster-randomized to continue to receive standard implementation or enhanced implementation (audit and feedback reports and external facilitation via guided interviews to assess VABA use barriers). Percentages of facilities adopting VABA at baseline, after standard implementation (Follow-up 1), and after the enhanced vs. standard implementation trial period (Follow-up 2) were assessed and compared across time points using McNemar's test. VABA adoption was compared by trial condition using Fisher's exact test.

RESULTS: Before education, 25% of 167 MPC/IP survey respondents across 116 facilities reported no knowledge/use of VABA. After education, 82% of 92 survey respondents across 80 facilities reported intending to use VABA. At baseline, VABA registrations were 40%. Registrations significantly increased aft Follow-up 1(75%, p < 0.01) and at Follow-up 2 (89%, p < 0.01). Adoption did not significantly differ by assigned implementation condition but was higher among facilities that completed all components of enhanced implementation than those who did not (87.5% vs. 43.5%, p = 0.045). Guided interviews revealed key facilitators of VABA registration, which included perceived fit, implementation activities, and organizational context (e.g., staffing resources).

CONCLUSIONS: Implementation efforts dramatically increased VABA registrations. Incorporating interview feedback to increase VABA's fit with users' needs may increase its use and help reduce MDRO spread in VA.

BACKGROUND: Global shortages for 3 angiotensin receptor-II blockers (ARBs)-valsartan, losartan, and irbesartan-occurred in 2018-2019 after recalls due to ingredient impurities. Provider-level responses to the ARB shortages in the United States and spillovers to other antihypertensive classes are unknown.

OBJECTIVE: To estimate changes in provider-level prescribing for ARBs and non-ARB antihypertensives up to 18 months after the 2018-2019 recalls and shortages.

RESEARCH DESIGN: National cohort study of prescribers using all-payer pharmacy claims. Mixed interrupted time series models quantified changes in prescribing postshortages and heterogeneous changes by specialty, region, medical school graduation cohort, sex, and level of prerecall prescribing.

PATIENTS AND METHODS: Active providers exposed to the 2018-2019 valsartan, irbesartan, and losartan shortages (defined as top-25th percentile for these drugs in 2017).

MEASURES: Within-class changes in prescribing for ARBs (recalled and nonrecalled). Between-class substitutions to non-ARB antihypertensives (ACE-Is, alpha- and beta-adrenergic blockers, calcium channel blockers, diuretics, and other agents).

RESULTS: Among 138,032 prescribers who met the inclusion criteria, per-prescriber fills for valsartan decreased by 57%-59% after it was recalled in July 2018. We observed concurrent increases for losartan and irbesartan fills and no change in overall ARB prescribing. There were no significant changes in fills for ACE-Is or for other antihypertensives. Absolute decreases in valsartan fills were greatest among providers with higher levels of prescribing at baseline. However, relative changes did not differ by prescriber characteristics.

CONCLUSIONS: In this prescriber level, national study, substitutions to other ARBs mitigated decreases in valsartan fills after it was recalled. There were no spillovers to non-ARB anti-hypertensives. The availability of close substitutes during drug shortages may mitigate gaps in access for prescribers and their patients.

We conducted an interrupted time series analysis to assess changes in antibiotic sales in 37 countries that implemented National Action Plans (NAPs) between 2013 and 2018. Overall, NAP implementation was not associated with changes in antibiotic sales two years later, with country-specific effects ranging from a 38.3% decrease to 65.3% increase.