Opioid Use for Pain Management After Implementation of a Medicaid Short-Acting Opioid Quantity Limit.

BACKGROUND: The United States is currently experiencing an opioid abuse epidemic. Many policies and programs have been implemented at local, state, and national levels in an attempt to decrease prescription opioid addiction and overdose. On August 1, 2014, Colorado Medicaid implemented a policy change that limited the quantity of short-acting opioids (SAOs) that could be filled through the Medicaid benefit to no more than 4 tablets per day, or 120 tablets in 30 days. OBJECTIVE: To compare mean total daily dose (TDD) of opioids purchased by Kaiser Permanente Colorado (KPCO) Medicaid patients before and after implementation of the Medicaid SAO quantity limit. METHODS: This investigation used a pre/post study design to compare opioid use in Medicaid-eligible patients during the 90 days before implementation of the Medicaid quantity limit on August 1, 2014, and 90 days after full implementation of the change on December 31, 2014. The study was conducted at KPCO, an integrated care delivery system providing medical care for approximately 615,000 patients, of which over 54,000 are Medicaid members. Electronic medical and pharmacy records were used to identify patients and assess medication use. RESULTS: There was a small difference in opioid use in the population of Medicaid opioid users as evidenced by the median TDD of oral morphine equivalents (OME) purchased decreasing from 6.8 mg (IQR = 2.2-25.8) in the pre-implementation period to 6.6 mg (IQR = 1.7-24.0) in the postimplementation period (P = 0.027). The proportion of patients purchasing more than 120 mg OME per day and the proportion of patients purchasing long-acting opioids (LAOs) did not change significantly from the pre- to postimplementation period (OME > 120 of 4.2% vs. 3.6%, respectively, P = 0.290; LAO use of 12.9% vs. 13.6%, respectively, P = 0.465). CONCLUSIONS: This study found a statistically significant 3% decrease of 0.2 mg OME per day in the primary study population. A 24% reduction of 10 mg OME per day before and after implementation of the Medicaid SAO quantity limit was found in those patients identified as exceeding the Medicaid SAO quantity limit at baseline. These patients tended to be purchasing low to moderate total daily doses of opioids at baseline. DISCLOSURES: Internal funding was provided by the Department of Pharmacy at Kaiser Permanente Colorado. There are no external funding sources to disclose. Riggs, Milchak, Patel, and Heilmann are employed by Kaiser Permanente Colorado. The authors report no other potential conflicts of interest. Study concept and design were contributed by Riggs, Heilmann, and Billups, along with the other authors. Billups collected the data, and data interpretation was performed by Riggs, Milchak, and Flores, with assistance from the other authors. The manuscript was written primarily by Riggs, along with Flores, and revised by Billups, Milchak, Patel, and Heilmann.

Labor costs and economic impact of a primary care clinical pharmacy service on postfracture care in postmenopausal women.

STUDY OBJECTIVE: To compare costs associated with two osteoporosis management interventions and to quantify cost avoidance due to projected hip fracture prevention. DESIGN: Labor and cost analysis within a retrospective cohort study. SETTING: Integrated health care delivery system. PATIENTS OR PARTICIPANTS: Women aged 67 or older with a documented fracture between January 1 and December 31, 2007, managed by either a Clinical Pharmacy Osteoporosis Management Service (CPOMS) or comparator service using a registered nurse (RN). Recommendations included dual-energy x-ray absorptiometry (DEXA) scans and/or bisphosphonate therapy as appropriate. MEASUREMENT AND MAIN RESULTS: The primary end points were cost per patient reviewed, cost per patient achieving the quality end point of completing a DEXA scan or purchasing an antiosteoporosis medication, and cost avoidance due to projected hip fracture prevention. A total of 1129 women were managed by either CPOMS (n=827) or the comparator service (n=302). The cost of provider time for CPOMS and comparator group interventions was $25 ($21-$30) and $34 ($21-$53) per patient reviewed, respectively. The cost per patient achieving the quality end point was $92 ($77-$112) and $198 ($124-$307), respectively. If women in the CPOMS group persisted in receiving their bisphosphonate for 1 year, approximately two additional hip fractures would be avoided per 1000 patients reviewed. Based on this model, the projected annual cost of osteoporosis care for 1000 women was $619,736 (CPOMS) versus $726,887 (comparator service). CONCLUSIONS: The CPOMS resulted in comparable cost per patient reviewed but a lower cost per patient achieving quality end points. When including costs associated with projected hip fractures, CPOMS was less expensive than the comparator group because more patients initiated drug therapy, which resulted in fewer projected hip fractures. From the health care payer's perspective, the CPOMS intervention is associated with a lower cost per patient achieving treatment recommendations while providing future cost savings because of fewer hip fractures.

Use of a pharmacy technician to facilitate postfracture care provided by clinical pharmacy specialists.

PURPOSE: The ability of a pharmacy technician to support the patient screening and documentation-related functions of a pharmacist-driven osteoporosis management service was evaluated. METHODS: A two-phase prospective study was conducted within a large integrated health system to assess a pharmacy technician's performance in supporting a multisite team of clinical pharmacy specialists providing postfracture care. In phase I of the study, a specially trained pharmacy technician provided support to pharmacists at five participating medical offices, helping to identify patients requiring pharmacist intervention and, when applicable, collecting patient-specific clinical information from the electronic health record. In phase II of the study, the amount of pharmacist time saved through the use of technician support versus usual care was evaluated. RESULTS: The records of 127 patient cases were reviewed by the pharmacy technician during phase I of the study, and a pharmacist agreed with the technician's determination of the need for intervention in the majority of instances (92.9%). An additional 91 patient cases were reviewed by the technician in phase II of the research. With technician support, pharmacists spent less time reviewing cases subsequently determined as not requiring intervention (mean ± S.D., 5.0 ± 3.8 minutes per case compared with 5.2 ± 4.5 minutes under the usual care model; p = 0.78). In cases requiring intervention, technician support was associated with a reduction in the average pharmacist time spent on care plan development (13.5 ± 7.1 minutes versus 18.2 ± 16.6 minutes with usual care, p = 0.34). CONCLUSION: The study results suggest that a pharmacy technician can accurately determine if a patient is a candidate for pharmacist intervention and collect clinical information to facilitate care plan development.

Evolution, current structure, and role of a primary care clinical pharmacy service in an integrated managed care organization.

The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.

Impact of a pharmacist-directed intervention in postmenopausal women after fracture.

PURPOSE: The impact of decentralized clinical pharmacy services on the implementation of appropriate care in postmenopausal women with a recent history of a fracture was assessed. METHODS: Women 67 years of age or older with a documented fracture between January 1 and December 31, 2007, were identified in two geographic regions. At the intervention site, a decentralized clinical-pharmacy-based osteoporosis management service (CPOMS) intervened on postmenopausal women following fracture, while the comparison group utilized a centralized registered nurse to manage this population. In both groups, interventions included initiation of either osteoporosis medication or bone mineral density (BMD) screening. RESULTS: Of the 827 women in the CPOMS group, 65% (523) initiated a medication for osteoporosis or completed BMD screening within 6 months of the fracture, compared with 46% (139) of the 302 women in the comparison group (p < 0.001; cumulative incidence ratio [CIR], 1.75; 95% confidence interval [CI], 1.44-2.12). CPOMS patients were nearly twice as likely as comparison group patients to purchase osteoporotic medications (42% [347 of 827] versus 24% [73 of 302]; CIR, 1.89; 95% CI, 1.50-2.40) and equally likely to undergo BMD testing (35% [289 of 827] versus 31% [94 of 302]; CIR, 1.13; 95% CI, 0.91-1.39). Both interventions achieved results substantially higher than national averages. Of patients receiving a medication and continuous membership for 12 months, adherence was also significantly higher in the CPOMS group (46% [39 of 291] versus 28% [20 of 71], respectively; p = 0.007). CONCLUSION: An integrated pharmacist-run osteoporosis management service demonstrated a substantial increase in the rate of osteoporosis drug initiation among post-menopausal women who experienced a fracture compared with a centrally located nurse-run service. BMD screening rates did not significantly differ between groups.