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Research in Social & Administrative... Jan 2023The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare... (Review)
Review
BACKGROUND
The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare insurance counseling provided by pharmacists, including individualized plan comparison and enrollment assistance, improves medication adherence and health care utilization, yet only 15% of community dwelling older adults report using a pharmacy or pharmacist for Medicare information. To determine what information is available to inform expanding implementation of pharmacy as a resource for Medicare insurance counseling, a systematic review of published studies using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted.
METHODS
Articles meeting inclusion criteria were identified through a literature search using PubMed and GoogleScholar; 27 pharmacy Medicare insurance counseling studies were identified representing 13 unique programs in clinical, community outreach, and community pharmacy settings. Each article was coded by two researchers using the RE-AIM Coding Sheet for Publications and the extent of RE-AIM dimension reporting was determined using descriptive statistics at the program level. Discussions were used to arrive at coding consensus and concordance was measured with Krippendorff's alpha.
RESULTS
Across all studies (15 quasi experimental, 10 analytical case reports, and 2 case reports) more than half of the programs reported framework component dimensions for Reach (69%), Adoption (58%), Implementation (54%), and Maintenance (54%), and fewer than half reported comprehensively on Effectiveness (44%). Ten studies in 7 of 13 programs reported estimated out-of-pocket cost savings. Two studies measured patient-centered outcomes: medication adherence by proportion of days covered (PDC) and health care utilization by hospital admissions and emergency department visits. Gaps in the external validity of pharmacy Medicare education programs were identified including staff participation rates, methods to identify participating settings and program costs.
CONCLUSIONS
Based on this review, current research on pharmacy Medicare education is insufficient to guide broad implementation. Additional studies are needed to determine how Medicare education integrating pharmacists and pharmacies can be implemented to address cost-related non-adherence for community dwelling older adults.
Topics: Aged; United States; Humans; Medication Therapy Management; Medicare; Pharmacists; Medication Adherence; Health Services Accessibility
PubMed: 36085121
DOI: 10.1016/j.sapharm.2022.08.013 -
The American Journal of Managed Care Aug 2022CMS' coverage with evidence development (CED) policy allows Medicare beneficiaries to access promising therapies and services while additional data are collected. CED...
OBJECTIVES
CMS' coverage with evidence development (CED) policy allows Medicare beneficiaries to access promising therapies and services while additional data are collected. CED program characteristics are mostly unreported, and qualities associated with retirement of CED data collection requirements are unknown. We aimed to review and systematically describe CED program history and components and report programmatic elements correlated with retirement of CED data collection requirements, while identifying areas for policy improvement.
STUDY DESIGN
Systematic review.
METHODS
We extracted CED information from the CMS website, ClinicalTrials.gov, PubMed, internet searches, and communication with CMS.
RESULTS
There were 27 CED determinations from 2005 to 2022 in 8 therapeutic areas, with the most for cardiovascular diseases (8/27; 30%). Duration of CED programs (range, 1-16 years) and the number of related registries and clinical trials (range, 0-34) were widely variable. Only 4 CEDs have had data collection requirements with continued National Coverage Determination (NCD); 3 relate to cardiovascular therapies, and all have some public availability of findings resulting from CED-related data collection mechanisms. There were 2 instances of NCD revocation and deferral to local coverage decisions.
CONCLUSIONS
Changes in the CED program through improving program predictability and transparency with regard to outstanding questions, roles of relevant stakeholders, and requirements for reporting and reevaluation would strengthen the program's effectiveness. Ultimately, these improvements would provide incentives for stakeholder participation in data collection to achieve the goal of increasing access to beneficial therapies and improving clinical outcomes.
Topics: Aged; Humans; Medicare; Noncommunicable Diseases; Program Development; Registries; United States
PubMed: 35981123
DOI: 10.37765/ajmc.2022.88870 -
Health Services Research Oct 2020To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics.
DATA SOURCE
Studies of adult patients with type 2 diabetes in MEDLINE published between January 1, 2000, and December 31, 2018.
STUDY DESIGN
Systematic review and meta-analysis of regression-based studies including race/ethnicity and income or education as explanatory variables. Meta-analysis was used to quantify differences in performance associated with patient race/ethnicity or socioeconomic characteristics. The systematic review was used to identify potential mechanisms of disparities.
DATA COLLECTION
Two coauthors separately conducted abstract screening, study exclusions, data extraction, and scoring of retained studies. Estimates in retained studies were extracted and, where applicable, were standardized and converted to odds ratios and standard errors.
PRINCIPAL FINDINGS
Performance in intermediate outcomes and process measures frequently exhibited differences by race/ethnicity even after adjustment for socioeconomic, lifestyle, and health factors. Meta-analyses showed black patients had lower odds of HbA1c and blood pressure (BP) control (OR range: 0.67-0.68, P < .05) but higher odds of receiving eye or foot examination (OR range: 1.22-1.47, P < .05) relative to white patients. A high school degree or more was associated with higher odds of HbA1c control and receipt of eye examinations compared to patients without a degree. Meta-analyses of income included a handful of studies and were inconsistently associated with diabetes care performance. Differences in diabetes performance appear to be related to access-related factors such as uninsurance or lacking a usual source of care; food insecurity and trade-offs at very low incomes; and lower adherence among younger and healthier diabetes patients.
CONCLUSIONS
Patient race/ethnicity and education were associated with differences in diabetes quality measures. Depending on the approach used to rate providers, not adjusting for these patient characteristics may penalize or reward providers based on the populations they serve.
Topics: Age Factors; Blood Pressure; Diabetes Mellitus, Type 2; Ethnicity; Glycated Hemoglobin; Health Behavior; Health Services Accessibility; Health Status; Humans; Life Style; Quality Indicators, Health Care; Quality of Health Care; Racial Groups; Sex Factors; Socioeconomic Factors
PubMed: 32720345
DOI: 10.1111/1475-6773.13326 -
Osteoporosis International : a Journal... Jan 2020Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for... (Meta-Analysis)
Meta-Analysis
Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. However, it is not well established how great the risk is for falls and fractures for the different stages of CKD compared to the general population. The objective of this systematic review and meta-analysis was to assess whether, and in which degree, CKD was associated with falls and fractures in adults. A systematic search in PubMed, Embase, CINAHL, and The Cochrane Library was performed on 7 September 2018. All retrospective, cross-sectional, and longitudinal studies of adults (18 years of older) that studied the association between CKD, fractures, and falls were included. Additional studies were identified by cross-referencing. A total of 39 publications were included, of which two publications assessed three types of outcome and four publications assessed two types of outcome. Ten studies focused on accidental falling; seventeen studies focused on hip, femur, and pelvis fractures; seven studies focused on vertebral fractures; and thirteen studies focused on any type of fracture without further specification. Generally, the risk of fractures increased when kidney function worsened, with the highest risks in the patients with stage 5 CKD or dialysis. This effect was most pronounced for hip fractures and any type of fractures. Furthermore, results on the association between CKD and accidental falling were contradictory. Compared to the general population, fractures are highly prevalent in patients with CKD. Besides more awareness of timely fracture risk assessment, there also should be more focus on fall prevention.
Topics: Accidental Falls; Adult; Aged; Case-Control Studies; Cohort Studies; Cross-Sectional Studies; Female; Fractures, Bone; Humans; Male; Medicare; Nutrition Surveys; Prospective Studies; Renal Insufficiency, Chronic; Retrospective Studies; United States
PubMed: 31720721
DOI: 10.1007/s00198-019-05190-5 -
The Cochrane Database of Systematic... May 2022Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce... (Review)
Review
BACKGROUND
Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.
OBJECTIVES
To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.
SELECTION CRITERIA
We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.
MAIN RESULTS
We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.
AUTHORS' CONCLUSIONS
The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.
Topics: Aged; Drug and Narcotic Control; Health Expenditures; Humans; Insurance, Pharmaceutical Services; National Health Programs; Prescription Drugs
PubMed: 35502614
DOI: 10.1002/14651858.CD011703.pub2 -
Blood May 2020There may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the... (Meta-Analysis)
Meta-Analysis
There may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the certainty of the evidence have not been published. We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients and searched Medline and EMBASE from inception through May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Of 69 410 citations, we included 17 studies in our analysis: 14 that reported on VTE, and 3 that reported on bleeding. For VTE, moderate-certainty evidence showed a probable association with older age; elevated C-reactive protein (CRP), D-dimer, and fibrinogen levels; tachycardia; thrombocytosis; leukocytosis; fever; leg edema; lower Barthel Index (BI) score; immobility; paresis; previous history of VTE; thrombophilia; malignancy; critical illness; and infections. For bleeding, moderate-certainty evidence showed a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication, and presence of a central venous catheter. Elevated CRP, a lower BI, a history of malignancy, and elevated heart rate are not included in most VTE risk assessment models. This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding; it also informs guidelines for VTE prevention and future research.
Topics: Adult; Age Factors; Aged; Aged, 80 and over; Comorbidity; Female; Hemorrhage; Hospitalization; Humans; Male; Middle Aged; Prognosis; Risk Factors; Venous Thromboembolism
PubMed: 32092132
DOI: 10.1182/blood.2019003603 -
Journal of Medical Internet Research Feb 2021Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the...
BACKGROUND
Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization.
OBJECTIVE
The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use.
METHODS
Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor.
RESULTS
Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor.
CONCLUSIONS
Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.
Topics: Humans; Patient Participation; Patient Portals; Utilization Review
PubMed: 33629962
DOI: 10.2196/23493 -
Mayo Clinic Proceedings. Innovations,... Apr 2021To systematically evaluate the prevalence of disclosed and undisclosed financial conflicts of interest (FCOI) among clinical practice guidelines (CPGs). (Review)
Review
OBJECTIVE
To systematically evaluate the prevalence of disclosed and undisclosed financial conflicts of interest (FCOI) among clinical practice guidelines (CPGs).
METHODS
In this systematic review, we ascertained the prevalence and types of FCOI for CPGs from January 1, 1980, to March 3, 2019. The primary outcome was the prevalence of FCOI among authors of CPGs. FCOI disclosures were compared between medical subspecialties and societies producing CPGs.
RESULTS
Among the 37 studies including 14,764 total guideline authors, 45% had at least one FCOI. The prevalence of FCOI per study ranged from 6% to 100%. More authors had FCOI involving general payments (39%) compared with research payments (29%). Oncology, neurology, and gastroenterology had the highest prevalence of FCOI compared with other medical specialties. Among the 8 studies that included the monetary values in US dollars of FCOI, average payments per author ranged from $578 to $242,300. Among the 10 studies that included data on undisclosed FCOI, 32% of authors had undisclosed industry payments.
CONCLUSION
There are numerous FCOI among authors of CPGs, many of which are undisclosed Our study found a significant difference in FCOI prevalence based on types of FCOI and CPG sponsor society. Additional research is required to quantify the implications of FCOI on clinical judgment and patient care.
PubMed: 33997642
DOI: 10.1016/j.mayocpiqo.2020.09.016 -
International Journal of Medical... Apr 2023Poorly designed electronic medication management systems (EMMS) or computerized physician order entry (CPOE) systems in hospital settings can result in usability issues... (Review)
Review
INTRODUCTION
Poorly designed electronic medication management systems (EMMS) or computerized physician order entry (CPOE) systems in hospital settings can result in usability issues and in turn, patient safety risks. As a safety science, human factors and safety analysis methods have potential to support the safe and usable design of EMMS.
OBJECTIVE
To identify and describe human factors and safety analysis methods that have been used in the design or redesign of EMMS used in hospital settings.
MATERIALS AND METHODS
A systematic review, following PRISMA guidelines, was conducted by searching online databases and relevant journals from January 2011 to May 2022. Studies were included if they described the practical application of human factors and safety analysis methods to support the design or redesign of a clinician-facing EMMS, or its components. Methods used were extracted and mapped to human centered design (HCD) activities: understanding context of use; specifying user requirements; producing design solutions; and evaluating the design.
RESULTS
Twenty-one papers met the inclusion criteria. Overall, 21 human factors and safety analysis methods were used in the design or redesign of EMMS with prototyping, usability testing, participant surveys/questionnaires and interviews the most frequent. Human factors and safety analysis methods were most frequently used to evaluate the design of a system (n = 67; 56.3%). Nineteen of 21 (90%) methods used aimed to identify usability issues and/or support iterative design; only one paper utilized a safety-oriented method and one, a mental workload assessment method.
DISCUSSION AND CONCLUSION
While the review identified 21 methods, EMMS design primarily utilized a subset of available methods, and rarely a method focused on safety. Given the high-risk nature of medication management in complex hospital environments, and the potential for harm due to poorly designed EMMS, there is significant potential to apply more safety-oriented human factors and safety analysis methods to support EMMS design.
Topics: Humans; Medication Therapy Management; Medical Order Entry Systems; Medication Systems, Hospital; Patient Safety
PubMed: 36809716
DOI: 10.1016/j.ijmedinf.2023.105017 -
BMJ Open Mar 2023The aim of this study is to investigate the effect of artificial intelligence (AI) and/or algorithms on drug management in primary care settings comparing AI and/or...
OBJECTIVES
The aim of this study is to investigate the effect of artificial intelligence (AI) and/or algorithms on drug management in primary care settings comparing AI and/or algorithms with standard clinical practice. Second, we evaluated what is the most frequently reported type of medication error and the most used AI machine type.
METHODS
A systematic review of literature was conducted querying PubMed, Cochrane and ISI Web of Science until November 2021. The search strategy and the study selection were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Population, Intervention, Comparator, Outcome framework. Specifically, the Population chosen was general population of all ages (ie, including paediatric patients) in primary care settings (ie, home setting, ambulatory and nursery homes); the Intervention considered was the analysis AI and/or algorithms (ie, intelligent programs or software) application in primary care for reducing medications errors, the Comparator was the general practice and, lastly, the Outcome was the reduction of preventable medication errors (eg, overprescribing, inappropriate medication, drug interaction, risk of injury, dosing errors or in an increase in adherence to therapy). The methodological quality of included studies was appraised adopting the Quality Assessment of Controlled Intervention Studies of the National Institute of Health for randomised controlled trials.
RESULTS
Studies reported in different ways the effective reduction of medication error. Ten out of 14 included studies, corresponding to 71% of articles, reported a reduction of medication errors, supporting the hypothesis that AI is an important tool for patient safety.
CONCLUSION
This study highlights how a proper application of AI in primary care is possible, since it provides an important tool to support the physician with drug management in non-hospital environments.
Topics: Humans; Child; Artificial Intelligence; Medication Therapy Management; Medication Errors; Patient Safety; Primary Health Care
PubMed: 36958780
DOI: 10.1136/bmjopen-2022-065301