<p>In 1999, Saskatchewan Health sanctioned licensed pharmacists in the province to initiate Exception Drug Status (EDS), also referred to as prior approval, requests on behalf of their patients. The objectives of this study were to obtain pharmacists opinions about the benefits of the EDS program to stakeholders, and to identify factors associated with pharmacists initiating a request.</p><p>In the fall of 2004, a census of community-pharmacy managers in Saskatchewan was conducted using a postal questionnaire, consisting of an introductory letter, two survey mailings and one reminder card. The questionnaire consisted primarily of seven-point Likert scale questions, and was analyzed using descriptive statistics and frequencies, followed by non-parametric analysis using Mann-Whitney U and Kruskal-Wallis tests; post-hoc analysis was carried out using the Bonferroni test.</p><p>A response rate of 82.6% was achieved. Those living in Saskatoon or Regina made up 39% of respondents, with another 39% located in centres of less than 5,000 people.</p><p>A majority of respondents (63%) agreed or strongly agreed the EDS program benefited patients and the Drug Plan (64%). Only 15%, 37% and 39% of respondents agreed or strongly agreed EDS benefits pharmacists, physicians and the health care system respectively.</p><p>Factors that were important or very important to pharmacists in deciding whether they would initiate an EDS request on behalf of their patient were: the ability of the pharmacist to obtain the required information to initiate the EDS request (77%); their ability to contact the prescribing physician (70%); and patient centred concerns such as the ability to pay (74%) or the patient had exceeded their deductible (66%). However, time (39%) was not as important relative to other factors in whether the pharmacist would apply for EDS on behalf of their patient.</p><p>The majority of respondents agreed or strongly agreed that changing the policy in 1999 was beneficial to patient care (71%), while it also contributed substantially to their administrative workload (87%). </p><p>The results of this study indicate community pharmacy managers in Saskatchewan acknowledge that the Exception Drug Status process is beneficial for their patients. While pharmacists were supportive of the benefits of an EDS program, their apprehensions towards the program lie in the administrative processes, particularly in obtaining the required information, from physicians, to submit a claim. There is also concern with the methods pharmacists must use to apply for EDS, which can be burdensome and prolong the administrative process.</p><p>To enhance pharmacists support for the program it may be necessary to develop strategies designed to reduce the administrative workload associated with the program, and to streamline the efficient communication of required information between the prescriber and pharmacist. Alternatively, financial compensation to pharmacists for their expertise and efforts might be considered; although this would not address the workload and communication concerns of pharmacists, it does provide recognition for their professional role in securing appropriate drug therapy for their patients.

<p>In 1999, Saskatchewan Health sanctioned licensed pharmacists in the province to initiate Exception Drug Status (EDS), also referred to as prior approval, requests on behalf of their patients. The objectives of this study were to obtain pharmacists opinions about the benefits of the EDS program to stakeholders, and to identify factors associated with pharmacists initiating a request.</p><p>In the fall of 2004, a census of community-pharmacy managers in Saskatchewan was conducted using a postal questionnaire, consisting of an introductory letter, two survey mailings and one reminder card. The questionnaire consisted primarily of seven-point Likert scale questions, and was analyzed using descriptive statistics and frequencies, followed by non-parametric analysis using Mann-Whitney U and Kruskal-Wallis tests; post-hoc analysis was carried out using the Bonferroni test.</p><p>A response rate of 82.6% was achieved. Those living in Saskatoon or Regina made up 39% of respondents, with another 39% located in centres of less than 5,000 people.</p><p>A majority of respondents (63%) agreed or strongly agreed the EDS program benefited patients and the Drug Plan (64%). Only 15%, 37% and 39% of respondents agreed or strongly agreed EDS benefits pharmacists, physicians and the health care system respectively.</p><p>Factors that were important or very important to pharmacists in deciding whether they would initiate an EDS request on behalf of their patient were: the ability of the pharmacist to obtain the required information to initiate the EDS request (77%); their ability to contact the prescribing physician (70%); and patient centred concerns such as the ability to pay (74%) or the patient had exceeded their deductible (66%). However, time (39%) was not as important relative to other factors in whether the pharmacist would apply for EDS on behalf of their patient.</p><p>The majority of respondents agreed or strongly agreed that changing the policy in 1999 was beneficial to patient care (71%), while it also contributed substantially to their administrative workload (87%). </p><p>The results of this study indicate community pharmacy managers in Saskatchewan acknowledge that the Exception Drug Status process is beneficial for their patients. While pharmacists were supportive of the benefits of an EDS program, their apprehensions towards the program lie in the administrative processes, particularly in obtaining the required information, from physicians, to submit a claim. There is also concern with the methods pharmacists must use to apply for EDS, which can be burdensome and prolong the administrative process.</p><p>To enhance pharmacists support for the program it may be necessary to develop strategies designed to reduce the administrative workload associated with the program, and to streamline the efficient communication of required information between the prescriber and pharmacist. Alternatively, financial compensation to pharmacists for their expertise and efforts might be considered; although this would not address the workload and communication concerns of pharmacists, it does provide recognition for their professional role in securing appropriate drug therapy for their patients.

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In light of drastically escalating costs for today’s medications, pharmacy benefit managers are seeking a constant balance of effectiveness and cost control. Step Therapy helps to address these concerns with a try medication “A” before medication “B” logic. Like all medical interventions, the possibility of unintended consequences exists. The purpose of this study was to determine if non-adherence results from application of Step Therapy for selected medication classes (antihyperlipidemics (specifically the HMG Co-A reductase inhibitors), angiotensin receptor blockers, uro-selective alpha-blockers, and dipeptidyl peptidase-4 inhibitors) in the Department of Defense. Using a retrospective database analysis, this study examined the primary adherence rate of subjects after they have been denied coverage due to Step Therapy intervention. Additionally, this study examined the association of demographic and service-related factors with the likelihood that a patient will be non-adherent after encountering the intervention. Finally, the study measured the time to adherence after intervention for those who were persistent after a Step Therapy claim rejection. STATA version 10.0 was used to conduct logistic regression analyses to meet the study objectives. After examination of 279,508 claims for 27,202 subjects, the estimated primary non-adherence rate following the Step Therapy intervention for all medication classes combined was 15.1%. Additionally, there was inter-class variability in this rate ranging between 13.1% and 19.5%. A statistical and practical difference was also noted in non-adherence rates between subjects who received care at the retail point of service versus those who received care at the mail order point of service. Subjects who received care through retail were nearly twice as likely to be non-adherent as those who received care in the mail order segment. For those subjects who were persistent with therapy, the median time-to-fill was estimated at 7 days. The occurrence of non-adherence following a Step Therapy intervention was clearly demonstrated through this study. Although this study provides good framework for designing interventions after claim rejection, further research would help to determine the health impact of primary non-adherence as well as the economic consequences of the intervention. / text

Introduction: The volume of antipsychotic medications prescribed to children and adolescents has risen sharply since second generation antipsychotics, also referred to as atypical antipsychotics, were introduced in the 1990’s. The concern surrounding the expanded use of antipsychotics was that the medications have significant adverse metabolic side effects and they were often prescribed to treat conditions in young children for which they have not been proven to be safe and effective. While it is not unlawful for health care providers to prescribe medications for uses beyond which they have been approved by the United States Food and Drug Administration, the lack of empirical evidence guiding much of the antipsychotic use in children had professional pediatric medical groups and policy makers concerned for the well-being of children receiving the medications. Several states, including Pennsylvania, enacted prior authorization policies in an attempt to restrict prescribing to children where a medical need has been established. However, the impact of the policies is largely unknown since published data on the topic is sparse. Methods: This retrospective, medical claims-based cohort study, used de-identified administrative Medicaid data from January 2008 to December 2010 to investigate the impact of Pennsylvania’s September 2008 antipsychotic prior authorization policy on antipsychotic prescribing prevalence in children targeted by the policy. Descriptive methods and segmented regression of the interrupted time series were used to assess the effects of the policy on monthly antipsychotic prescribing prevalence. A difference-in-difference analysis compared Pennsylvania’s prescribing to Ohio, a geographically proximate and demographically similar state without a prior authorization policy; and Delaware, a state that enacted a policy 3 years prior to Pennsylvania. The potential for compensatory prescribing was assessed by reporting the prevalence of other psychotropic medications over the study period. Results: An average of 99,074 Pennsylvania Medicaid enrollees ages 0-6 were identified as meeting the study criteria annually from 2008-10. Immediately following the policy intervention, an abrupt, significant reduction in monthly prescriptions of antipsychotics was observed (-51 prescriptions per 100,000; p=0.0052) and sustained over the observation period. The proportion of children filling prescriptions for antipsychotics dropped approximately 46% and the average number of antipsychotic prescriptions filled per month was reduced by 53% in 2010 compared to 2008. In Ohio, a state without such a policy, the proportion of children receiving an antipsychotic increased nearly 10% in 2010 compared to 2008 and the average number of monthly prescriptions increased 30%. Reductions in antipsychotic prescribing in Delaware, a state that had its antipsychotic policy in place since 2005, were comparable to Pennsylvania. There was no evidence that non-antipsychotic psychotropic medications were prescribed in place of the medications restricted by the policy. Conclusions: Pennsylvania’s 2008 prior authorization policy was associated with a significant decrease in annual and monthly antipsychotic prescribing prevalence in Medicaid-insured children targeted by the policy, those ages 0-6 years of age. Reductions in most other psychotropics was also observed, indicating changes in prescribing behavior may have extended beyond antipsychotics. While this analysis suggests the policy may have achieved its primary aim of reducing antipsychotic prescribing, more research is needed to better understand the complex array of factors influencing provider behavior and to explore potential unintended consequences of the policy. / Public Health