Elizabeth C. S. Swart

Background: Hypertension is common during and after pregnancy. Patterns of antihypertensive medication discontinuation (AMD) in the postpartum period are not well characterized. This study examined factors associated with AMD among postpartum women. Methods: A retrospective claims analysis was conducted using the Komodo Health Healthcare Map. The study included 63,312 postpartum women aged 18-64 years who delivered between January 1, 2019, and December 31, 2022, and initiated an antihypertensive medication within 30 days after live delivery. AMD was defined as the absence of any anti-hypertensive medication from index medication (days’ supply + 30-day). Multivariable Poisson regression models with a log link and robust variance estimators were used. Results: Discontinuation occurred in 57.8% (36,576) of women. In adjusted analyses, older age was associated with lower risk of AMD compared with women aged 18-24 years (RR 0.93, 95% CI 0.93, 0.94 for ages 25-34; RR 0.89, 95% CI 0.88, 0.90 for ages 35-44; RR 0.85, 95% CI 0.82, 0.88 for ages ≥45). Hispanic (RR 1.03, 95% CI 1.02, 1.04) and Asian (RR 1.02, 95% CI 1.01, 1.04) women had higher risk of discontinuation compared with White women. Women with eclampsia (RR 0.97, 95% CI 0.97, 0.98), baseline hypertension (RR 0.95, 95% CI 0.95, 0.96), and postpartum depression (RR 0.95, 95% CI 0.94, 0.96) had lower risk of discontinuation. Conclusions: Postpartum AMD was common in this national claims-based cohort. Differences across demographic and clinical subgroups highlight patient populations that may benefit from directed postpartum blood pressure follow-up and medication management.

Chronic diseases such as diabetes are a major burden to the US health care system. High medication adherence helps improve diabetes outcomes and reduce cost. Cost of medications can contribute to nonadherence. Use of a formulary decision support system with e-prescribing may be associated with greater use of generic medications, leading to lower costs and better adherence. A real-time prescription benefit (RTPB) solution provides patient-specific drug pricing, benefit information, and therapeutic options to choose the most cost-effective and clinically appropriate treatment. To examine whether RTPB is associated with increased adherence measured by proportion of days covered, higher utilization of generics, and generic dispensing rate? Is RTPB associated with lower plan and patient out-of-pocket (OOP) per-user per-month costs? This study used a retrospective, matched intervention-control analysis of commercial health plan members from a large pharmacy benefits manager. Members were eligible for inclusion if they initiated therapy between January and August 2021. Members were excluded if they were not continuously eligible for coverage over the study period. Members who initiated diabetes therapy with a prescriber using RTPB (intervention) were compared with those new to therapy with a prescriber not using RTPB (control). Index date for both samples was the first medication prescription in the index period. Members were matched on age and sex demographics. The evaluation period lasted 12 months after index date. Multivariable linear regression models were used to assess the impact of an RTPB program on adherence and proportion of prescriptions filled with a generic. A generalized linear model (gamma distribution, log link) estimated plan and OOP patient costs, whereas a generalized linear model model with the Poisson distribution was used to estimate the number of controlling for patient age, sex, social determinants of health score, and other patient- and plan-level covariates. 1,302 matched pairs were included in the analysis. Findings show the proportion of days covered was 68.7% for control and 71.4% for RTPB members (P < 0.05). The average number of generic prescriptions for control and RTPB samples were 4.06 and 5.66, respectively (P < 0.05) and the generic dispensing rates were 44.9% and 60.1%, respectively (P < 0.05). The mean plan cost per member per month for diabetes medications, for the non-RTPB group, was 32.3% higher than the RTPB sample (a difference of $81.69, P < 0.0001) and the mean patient cost per month was 88.8% higher than the RTPB sample (a difference of $9.71, P < 0.0001). Access to RTPB tools provides prescribers with formulary benefit and therapeutic options that allow them to provide the lowest-cost clinical treatment, thus improving adherence, increasing use of generic medications, and lowering plan and patient OOP costs.

Outcomes-based agreements (OBAs) are agreements between payers and manufacturers in which payment for medications is tied to patient outcomes. These contracts aim to measure the value of prescription medications on predefined clinical indicators in real-world patient populations. OBAs are gaining traction in the United States as the health care industry shifts from volume-based to value-based care. Multiple sclerosis (MS) is an appealing therapeutic area for OBAs because of its prevalence, high cost of medications, and multiple effective therapeutic options. To describe findings from an OBA that was prospectively conducted in a large regional health system for patients with MS taking interferon β-1a or dimethyl fumarate. In this prospective real-world analysis, commercial or health insurance exchange members were included based on the parameters of the OBA. Disability progression was assessed using a patient-reported outcome, patient-determined disease steps (PDDS). In the OBA, members aged 18 years or older with an MS diagnosis were included in the contract. A baseline score was collected for eligible members, with follow-up scores occurring between a 90-day and 180-day postbaseline score. If a follow-up score was greater than the baseline score, a subsequent PDDS score was collected between 90-days and 120-days to determine if the PDDS score remained elevated, indicating that the member had disability progression. During the contract period, 410 patients were eligible for PDDS collection, with 241 and 169 patients in the dimethyl fumarate and interferon β-1a cohorts, respectively. There were 162 patients who were lost to follow-up, and 64 patients who were ineligible per contract parameters. Of the remaining 184 eligible patients (107 on dimethyl fumarate and 77 on interferon β-1a), 21 (11%) patients had confirmed disability progression (6 on dimethyl fumarate [5.6%] and 15 on interferon β-1a [19.5%]). Our findings suggest that meaningful patient-reported outcomes, such as disability progression, can be operationalized in an innovative OBA.

BACKGROUND: Although metformin is generally universally recommended as a first-line pharmacologic therapy for most people living with type 2 diabetes, second-line and third-line choices can require...

Background: Examine baseline factors associated with a new diagnosis of opioid use disorder (OUD) within 12 months postdischarge among opioid‐naïve patients who received an opioid prescription in the inpatient setting.Design/Setting: Retrospective cohort (surgery and nonsurgery) study of opioid‐naive patients who had at least one prescription for an opioid during an inpatient hospitalist between 2014 and 2017.Participants: Twenty‐three thousand and thirty‐three patients were included.Objective: The primary objective was to determine baseline factors associated with a new OUD diagnosis within 12 months of discharge. Baseline covariates included demographic information, clinical characteristics, medication use, characteristics related to index hospital encounter, and discharge location.Findings: 2.1% of the sample had a new diagnosis of OUD within a year after receiving an opioid during hospital admission. Patients between ages 25 and 34 had higher odds of a new OUD diagnosis compared to those 65 years of age and older (odds ratio [OR]: 6.98, 95% confidence interval [CI]: 4.02–12.1 [nonsurgery] and 4.69, 95% CI: 2.63–8.37 [surgery]). Patients from a high opioid geo‐rank region had higher odds of OUD diagnosis (OR: 2.08, 95% CI: 1.31–3.31 [nonsurgery] and 1.80, 95% CI: 1.03–3.15 [surgery]). History of nonopioid‐related drug disorder, tobacco use disorder, mental health conditions, and gabapentin use 12 months prior to index date and white race were associated with higher odds of new OUD diagnosis.Conclusions: It is important to identify and evaluate factors associated with developing a new diagnosis of OUD following hospitalization. This can inform pain management strategies within the hospital and at discharge, and prompt clinicians to screen for risk of OUD.

Background Acute coronary syndrome (ACS)-related readmission is an important hospital quality measure. Medication management therapy, especially adherence to antiplatelet agents post discharge, could play an important role in reducing readmission rates. Newer agents such as ticagrelor and prasugrel have been shown, in randomized control trials, to have superior effectiveness to cardiovascular outcomes compared to clopidogrel, but they are more expensive and have more common adverse events such as bleeding and dyspnea. Objective We compared real-world readmission rates and adherence to antiplatelet agents among patients who initiated these agents post discharge. Methods This was a retrospective cohortstudy of patients with an index ACS-related hospitalization between 1 July 2017 and 31 December 2018. Using integrated pharmacy and medical claims data from a large national pharmacy benefits manager for commercially insured adults aged ≥ 18 years, we compared ACS-related readmission and medication adherence (as medication possession ratio (MPR)) among the three agents. ANOVA and logistic regression, controlling for demographics such as age, gender, and Charlson Comorbidity Index, were used to estimate any association between the agents and 365-day readmission rates. Results Of the 948 eligible patients, 86, 342, and 520 were initiated on prasugrel, ticagrelor, and clopidogrel (PTC), respectively. There were 4.7%, 5.3%, and 8.5% readmissions rates in the PTC cohorts, respectively, but these were not statistically significant in either the ANOVA or the logistic regression analyses. MPR was highest in the ticagrelor (88.1%) cohort, followed by the prasugrel (79.1%) and clopidogrel (76.4%) cohorts. Conclusion Ticagrelor cohort had the highest medication adherence. Clopidogrel cohort had the highest readmission rate but the difference with the other cohorts was statistically insignificant.