The impact of the Choosing Wisely Canada campaign on the simultaneous use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers: interrupted time-series analysis.

BACKGROUND: Choosing Wisely is a high-profile campaign seeking to reduce the use of low-value care. We investigated the impact of a Choosing Wisely Canada recommendation against using a combination of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) for the management of hypertension, heart failure or diabetic nephropathy on population-level use of these medications in British Columbia, Canada. METHODS: We identified all people (any age) who were continuously registered with BC's Medical Service Plan between 2010 and 2017 with the targeted conditions. Using prescription claims data and an interrupted time-series analysis, we estimated the number of people on combination therapy per month, the proportion of days covered (PDC) by combination therapy per month and proportion of all combination prescriptions started per month in the 2 years before and after the introduction of the recommendation on Oct. 29, 2014. RESULTS: Of 1 104 593 people (mean age 65 yr, standard deviation 16 yr) in our study cohort, 4.6% were exposed to combination therapy, largely prescribed by family physicians (84%). The number of people on combination therapy and the PDC were declining before the recommendation, but the proportion of combination prescriptions started in the 2 years before the recommendation was increasing. After the recommendation, we observed no statistically significant changes in any outcome. The pre-existing downward trend of the monthly number of people decelerated (16.8, 95% confidence interval [CI] 14.0 to 19.5) and the proportion of prescriptions started increased (0.13%, 95% CI 0.08% to 0.18%). INTERPRETATION: The Choosing Wisely Canada recommendation against using a combination of ACE inhibitors and ARBs was not associated with reduced combination therapy use in the targeted conditions. The observed pre-existing declines in this practice questions the process of selecting recommendations, and the optimal implementation and value of Choosing Wisely campaigns without other reinforcing interventions.

What happens to drug use and expenditure when cost sharing is completely removed? Evidence from a Canadian provincial public drug plan.

OBJECTIVES: The role of cost-sharing for medicines is under active policy discussion, including in proposals for value-based insurance design. To inform this debate, we estimated the impact of completely removing cost-sharing on medication use and expenditure using a quasi-experimental approach. METHODS: Fair PharmaCare, British Columbia's income-based public drug plan, includes a household out-of-pocket limit. Therefore, when one household member starts a long-term high-cost drug surpassing this maximum, cost-sharing is completely removed for other family members. We used an interrupted time series design to estimate monthly prescriptions and expenditures of other household members, 24 months before and after cost-sharing removal. RESULTS: We studied 2191 household members newly free of cost-sharing requirements, most of whom had lower incomes. R emoving cost-sharing increased the level of drug expenditure and prescription numbers by 16 and 19%, respectively (i.e. $2659.43 (95%$1507.27-$3811.59, p < 0.001); 50.0 (95%CI 25.1-74.9, p < 0.001)) relative to prior expenditures and utilization without changing pre-existing trends. Much of this change was driven by 533 individuals initiating medication for the first time after cost-sharing removal. This initiation substantially increased average expenditure, especially for antiviral agents. CONCLUSIONS: Completely removing cost-sharing, independent of health status, significantly increased medication use and expenditure particularly due to medicine initiation by new users. While costs may be preventing use, the appropriateness of additional use, especially among new users, is unclear.

Impact of brand drug discount cards on private insurer, government and patient expenditures.

BACKGROUND: Brand discount cards have become a popular way for patients to reduce out-of-pocket spending on drugs; however, controversy exists over their potential to increase insurers' costs. We estimated the impact of brand discount cards on Canadian drug expenditures. METHODS: Using national claims-level pharmacy adjudication data, we performed a retrospective comparison of prescriptions filled using a brand discount card matched to equivalent generic prescriptions between September 2014 and September 2017. We investigated the impact on expenditures for 3 groups of prescriptions: those paid only through private insurance, those paid only through public insurance and those paid only out of pocket. RESULTS: We studied 2.82 million prescriptions for 89 different medications for which brand discount cards were used. Use of discount cards resulted in 46% higher private insurance expenditures than comparable generic prescriptions (+$23.09 per prescription, 95% confidence interval [CI] $22.97 to $23.21). Public insurance expenditures were only slightly higher with cards: an increase of 1.3% or $0.37 per prescription (95% CI $0.33 to $0.41). Finally, out-of-pocket transactions using a card resulted in mean patient savings of 7% or $3.49 per prescription (95% CI -$3.55 to -$3.43). The impact varied widely among medicines across all 3 analyses. INTERPRETATION: The use of brand discount cards increased costs to private insurers, had little impact on public insurers and resulted in mixed impacts for patients. These effects likely resulted from private insurers reimbursing brand drug prices even when generics were available and from discount cards being adjudicated after claims were sent to other insurers in most cases. Patients and their clinicians should recognize that discount cards have mixed impacts on out-of-pocket costs.

Impact of a household-level deductible on prescription drug use among lower-income adults: a quasi-experimental study.

BACKGROUND: Several Canadian public drug plans have income-based deductibles, but we have limited data on their impact, particularly for vulnerable populations. Therefore, we studied the impact of deductibles in British Columbia's Fair PharmaCare program on drug use among lower-income adults. METHODS: We used a quasi-experimental regression discontinuity design to study the impact of BC rules that impose no deductible before receiving public coverage on households with incomes less than $15 000, a deductible of 2% of household income on those with incomes between $15 000 and $30 000, and a deductible of 3% of household income on those with incomes above $30 000. We studied the impact of these thresholds on public and total drug expenditures between 2003 and 2015 using 24 million person-years of data. RESULTS: Both thresholds decreased the proportion of beneficiaries receiving benefits, by 0.33 (95% confidence interval [CI] -0.34 to -0.30) and 0.05 (95% CI -0.064 to -0.032) respectively. There were also substantial reductions in the extent of public drug plan expenditures ($59.94 [95% CI -74.74 to -45.14] and $26.12 [95% CI -39.78 to -12.46], respectively). The change at the $15 000 threshold reduced patient drug expenditures by $26.00 (95% CI -45.48 to -6.51), or 7.2%. In contrast, we found no statistically significant change in total expenditures when households moved from a deductible of 2% to 3% at the $30 000 threshold. INTERPRETATION: Income-based deductibles considerably affected the extent of public subsidy for prescription drugs. For lower-income households making around $15 000, the deductible led to a reduction of 7.2% in overall drug use and costs. Although deductibles are a useful tool to limit public expenditures, policy-makers should be cautious in their use among vulnerable populations.

The impact of a physician detailing and sampling program for generic atorvastatin: an interrupted time series analysis.

BACKGROUND: In 2011, Manitoba implemented a province-wide program of physician detailing and free sampling for generic atorvastatin to increase use of this generic statin. We examined the impact of this unique combined program of detailing and sampling for generic atorvastatin on the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. METHODS: We conducted a retrospective study of Manitoba insurance claims data for all continuously enrolled patients who filled one or more prescriptions for a statin between 2008 and 2013. Data were linked to physician-level data on the number of detailing visits and sample provision. We used interrupted time series analyses to assess policy-related changes in the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin. RESULTS: The detailing program reached 31% (651/2103) of physicians who prescribed a statin during the study period. Collectively, these physicians prescribed 61% of statins dispensed in the province. Free sample cards were provided to 61% (394/651) of the detailed physicians. The program did not change the level or trend in the overall statin use rate and the total cost of statins or increase the number of patients switching from another branded statin to generic atorvastatin. We found the program had a small impact on atorvastatin's market share of new prescriptions, with a level increase of 2.6%. CONCLUSIONS: Though physician detailers were skilled at targeting high-prescribing physicians, a combined program of detailing visits and sample provision for generic atorvastatin did not lower overall statin costs or lead to switching from branded statins to the generic. The preceding introduction of generic atorvastatin appeared sufficient to modify prescribing patterns and decrease costs.

Impact of income-based deductibles on drug use and health care utilization among older adults.

BACKGROUND: Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults. METHODS: We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups. RESULTS: The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold. INTERPRETATION: A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups.

The impact of hospital experience with out-of-hospital cardiac arrest patients on post cardiac arrest care.

OBJECTIVE: Patient volume as a surrogate for institutional experience has been associated with quality of care indicators for a variety of illnesses. We evaluated the association between hospital experience with comatose out-of-hospital cardiac arrest (OHCA) patients and important care processes. METHODS: This was a population-based, retrospective cohort study using data from 37 hospitals in Southern Ontario from 2007 to 2013. We included adults with atraumatic OHCA who were comatose on emergency department arrival and survived at least 6h. We excluded patients with a Do-Not-Resuscitate order or severe bleeding within 6h of hospital arrival. Multi-level logistic regression models estimated the association between average annual hospital volume of OHCA patients and outcomes. The primary outcome was successful targeted temperature management (TTM) and secondary outcomes included TTM initiation, premature withdrawal of life-sustaining therapy, and survival with good neurologic function. RESULTS: Our analysis included 2723 patients. For every increase of 10 in the average annual volume of eligible patients, the adjusted odds increased by 30% for successful TTM (OR 1.29, 95% CI 1.03-1.62) and by 38% for initiating TTM (OR 1.38, 95% CI 1.11-1.72). No significant association between patient volume and other secondary outcomes was observed. CONCLUSIONS: Patients arriving at hospitals with more experience treating comatose post cardiac arrest patients are more likely to have TTM initiated and to successfully reach target temperature. Our findings have implications for regional systems of care and knowledge translation efforts aiming to improve quality of care for this patient population.

The PulsePoint Respond mobile device application to crowdsource basic life support for patients with out-of-hospital cardiac arrest: Challenges for optimal implementation.

BACKGROUND: PulsePoint Respond is a novel mobile device application that notifies citizens within 400 m (∼ 1/4 mile) of a suspected cardiac arrest to facilitate resuscitation. Our objectives were to (1) characterize users, and (2) understand their behavior after being sent a notification. We sought to identify challenges for optimal implementation of PulsePoint-mediated bystander resuscitation. METHODS: PulsePoint Respond users who sent a notification between 04/07/2012 and 06/16/2014 were invited to participate in an online survey. At the beginning of our study, PulsePoint Respond was active in more than 600 US communities. RESULTS: There were 1274 completed surveys (response rate 1448/6777, 21.4%). Respondents were firefighters (28%), paramedics (18%), emergency medical technicians (9%), nurses (7%), MDs (1%), other health care professionals (12%), and non-health care professionals (42%). Of those who received a PulsePoint notification, only 23% (189/813) responded to the PulsePoint notification. Of those who responded, 28% (52/187) did not arrive on scene. Of those who did arrive on scene, only 32% (44/135) found a person unconscious and not breathing normally. Of those who arrived on scene prior to emergency medical services and found a cardiac arrest victim, 79% (11/14) performed bystander cardiopulmonary resuscitation. CONCLUSIONS: Challenges for optimal implementation of PulsePoint Respond include technical aspects of the notifications (audio volume, precision of location information), excessive activation radii, insufficient user density in the community, and suboptimal cardiac arrest notification specificity. PulsePoint Respond has the potential to improve the community response to cardiac arrest, with 80% of responders attempting basic life support when they found a cardiac arrest victim prior to EMS.

Adverse health effects for individuals who move between HIV care centers.

BACKGROUND: Studies on patient mobility have focused on patients who become lost-to-follow-up (LTFU). Much less is known about patients who move with a planned transfer of care from one HIV center to another. We assess disease progression in patients who moved and then returned to our care compared with patients remaining or were LTFU. METHODS: We identified which patients left our HIV care program between January 01,2000, to January 01,2008, defined how they left (either moved or LTFU), and then determined the health status of returning patients. We examined the impact of the move on their health by comparing clinical measurements (eg, CD4, new AIDS) at their departure and on return. RESULTS: Forty-four percent of all patients left care; 38% of these returned. In contrast to those remaining in local care whose CD4 counts climbed, "moved" patients exhibited deterioration in both CD4 counts and incident AIDS comparable to LFTU patients. Only 1 in 3 patients who moved had our medical records requested by a new HIV center. CONCLUSIONS: We suspect that despite forward planning, a move may result in potential serious interruptions and/or disengagements of care. The potential harmful health effects can in some be equivalent becoming LTFU. Recognizing and addressing the potential disruption in care from a planned move may be of value in improving outcomes.