Our study highlights the unmet clinical need to develop and test feasible interventions to improve AET adherence in HR+ breast cancer survivors to extend their long-term survival.

BackgroundWhile many new medications may offer advantages over existing drugs, some newer drugs are reformulations of existing products that provide little innovation or incremental benefit while driving up drug costs. Despite the lack of benefit of these medications, prescribers may be motivated by payments made by the pharmaceutical industry. The objective of the study was to determine the association between payments made to physicians by the pharmaceutical industry and prescriptions for certain selected costly brand name drugs.MethodsThis was a cross-sectional, retrospective study linking the Open Payments Database and Medicare Part D Prescriber Public Use File for 2014, including 667,278 physicians who prescribed one of 6 brand-name drugs with less costly but similarly effective alternatives: lovastatin ER, almotriptan, amlodipine+olmesartan, ibuprofen+famotidine, saxagliptin+metformin and naproxen+esomeprazole. The primary outcome was the odds of a physician prescribing one of the selected drugs, and the primary predictor was the receipt of any payment from the pharmaceutical industry.ResultsThe odds of prescribing 3 of the 6 drugs were increased among physicians who received industry payment, compared to those without payment: amlodipine+olmesartan, aOR 1.42, (95% CI 1.36–1.49); saxagliptin+metformin, aOR 1.50, (95% CI 1.42–1.59); and naproxen+esomeprazole, aOR 1.45, (95% CI 1.25–1.68). Payment from the manufacturer of the specific drug, compared to not receiving payment from the drug’s manufacturer, was associated with increased odds of prescribing 4 of the 6 drugs: amlodipine+olmesartan, aOR 2.40, (95% CI 2.29–2.52), ibuprofen+famotidine, aOR 8.06, (95% CI 5.42–12.00), saxagliptin+metformin, aOR 2.21, (95% CI 2.10–2.34) and naproxen+esomeprazole, aOR 5.96, (95% CI 5.08–7.00).ConclusionsA physician-industry financial relationship was associated with increased odds of prescribing costly brand-name drugs of uncertain medical benefit. Patients, as healthcare consumers, should demand transparency from their physicians about payment from the pharmaceutical industry to increase shared decision-making. Physician and policy makers need increased awareness and reflection on how industry payment influences their prescribing practices.

Cardiovascular disease (CVD) remains a major global cause of morbidity and mortality, affecting 40% of women and 50% of men over their lifetime. 1,2 CVD is also a leading contributor to disease burden in adults aged 60 years and older, accounting for around 30% of the total burden. 3 Statin medications are the most widely used lipidlowering agents, with compelling clinical trial data demonstrating effectiveness in primary and secondary prevention of CVD as well as evidence showing significant reduction of cardiovascular-related mortality. 4-10 Despite these well-documented benefits, adherence and persistence to statins remain substandard. 4,11 High discontinuation rates have also been reported, with 50% of patients discontinuing within 1 year and increasing discontinuation over time, especially among elderly patients. 4,[11][12][13][14][15] In the United States, 33%-69% of all medication-related hospital admissions are attributable to poor medication adherence, resulting in an annual estimated cost of $100 billion. 16,17 About 40%-86% of older adults are nonadherent, [17][18][19] which is concerning because they usually experience a higher number of illnesses, use more medications, and are at risk of age-related cognitive decline. 20,21

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Hepatic encephalopathy (HE) is a complication occurring in patients with cirrhosis and is associated with neuropsychiatric and motor abnormalities. Symptomatic HE episodes almost always require hospitalization and the frequent recurrence of episodes is associated with poor prognosis and increased medical costs. The utilization of existing therapies for management of HE and adherence to them has yet to be evaluated using real-world claims data. The aim of this study was to evaluate HE drug regimens and adherence and their association with hospital readmissions in Medicare Advantage plan patients. This was a retrospective cohort study of patients discharged from a HE-related hospitalization or emergency room visit. Based on subsequent enrollment in the plan they were categorized into cohorts of 1 month, 3, and 6 months follow-up, and medication regimen was evaluated within the first month. The drugs evaluated included lactulose, rifaximin, and neomycin. Multivariable logistic regression was conducted to evaluate the association of drug regimen and medication adherence measured as proportion of days covered with HE readmissions. There were 347 patients hospitalized for HE with 184 patients having 30-day enrollment and either a drug refill or an outpatient visit in this duration. Medications were not refilled by 67 (36.4%) patients. Various drug regimens had different adherence with mean (standard deviation) proportion of days covered ranging from 0.56 (0.29) to 0.82 (0.16) at 3 months and 0.48 (0.3) to 0.77 (0.15) at 6 months. The results of logistic regression at 3 and 6 months did not show a significant association of medication use or medication adherence with hospital readmissions. Despite availability of therapy, medication utilization was alarmingly low after discharge of patients from HE-related hospitalization. Medication adherence was also low, which may affect the rate of recurrence and costs associated with readmissions. Efforts are needed in both care coordination of these patients to ensure they are prescribed appropriate medications and to enhance adherence to them.

BACKGROUND: Health plans and providers can increase quality by improving adherence to chronic disease medications included in star ratings among Medicare Advantage Part D (MAPD) plan enrollees. Research is needed to evaluate effective means of collaboration between health plans and providers. The Medication Adherence Tracker (MAT) is a health plan initiative to help primary care providers use outreach to improve their patients' adherence.OBJECTIVE: To quantify the contribution of structural and process factors on the success of a health plan-initiated tracking system in improving chronic disease medication adherence over 6 months. METHODS:The MAT quality improvement initiative was carried out in South Texas from June to December 2016. Health plan pharmacists used claims data to identify MAPD enrollees at risk of nonadherence to triple-weighted star medications: renin-angiotensin system antagonists, oral diabetes medications, and statins. Actionable reports were delivered biweekly to each provider, either by fax or in person, by embedded health plan nurses. Multivariable regression was used to evaluate sociodemographic and clinical factors as well as the role of provider outreach in increasing paid pharmacy claims and medication adherence as measured by proportion of days covered (PDC) > 0.8. RESULTS: Of 3,542 patients in 5 Texas physician-organized delivery system groups whose 67 providers received tracking reports from June through December 2016, 1,901 (54%) patients had more than 1 related prescription, and 3,064 (87%) received provider outreach on at least 1 prescription. 2,493 (70%) had at least 1 paid pharmacy claim. Provider outreach was associated with greater likelihood of paid prescription claims (relative risk [RR] = 4.59, 95% CI = 3.74-5.62) and greater year-end adherence (PDC > 0.8, RR = 1.86, 95% CI = 1.63-2.12) in multivariable predictive models. 95% CIs for age, gender, low-income subsidy eligibility, and number of prescriptions did not exclude the null value.CONCLUSIONS: Provider engagement is critical to effective health planprovider partnerships to overcome barriers, change behavior, and improve chronic disease care quality and population outcomes.

Context Guidelines recommend scheduled long acting basal and short acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world”, insulin therapy is complicated, with limited data on comparative effectiveness of different insulin strategies. Objective Evaluate the association of different insulin strategies with glucose control and hospital outcomes, after adjustment for patient and physician factors that influence choice of therapy. Design Retrospective, observational. Setting Academic hospital. Patients Non-critically ill hospitalized medical/surgical patients (n=4,558) receiving subcutaneous insulin ≥75% of the admission. Interventions Insulin therapy was grouped into 3 strategies within the first 48 hours: basal-bolus (BB: scheduled long and short/rapid n=2,358), sliding scale (SS: short/rapid acting n=1,855), or basal only (BO: long only: n=345). Main Outcome Measure(s) Glucose control: hypo-, hyper-, euglycemic days, mean glucose. Hospitalization: mortality, length of stay (LOS), readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40 (CI:2.04,2.82) (P< 0.001)) and fewer euglycemic days (0.90 (CI:0.85,0.97) (P=0.003)) than SS, whereas BO was associated with fewer hyperglycemic days ((0.70 (0.62,0.79) (P<0.001)), lower mean glucose (-18.03 (CI:-22.46, -12.61) (P< 0.001)) and more euglycemic days (1.22 (CI:1.09,1.37), (P< 0.001)) compared to SS. No difference in mortality, LOS and readmissions was found. However, decreased LOS was observed in the subgroup with a medical DRG (0.93 (CI:0.89,0.97) (P<0.001)). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

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