Republication of "Total Ankle Replacement Conversion to Tibiotalocalcaneal Arthrodesis With Bulk Femoral Head Allograft and Pseudoelastic Intramedullary Nail Providing Sustained Joint Compression".

Tibiotalocalcaneal (TTC) arthrodesis is commonly performed to salvage a failed total ankle replacement. These salvage procedures are complicated by significant bone loss from the ankle replacement and are associated with low patient satisfaction. Here, we describe 2 cases of patients who presented with a failed total ankle replacement and underwent arthrodesis using a bulk femoral head allograft and a novel pseudoelastic intramedullary nail. The intramedullary nail contains an internal pseudoelastic element that adapts to bone resorption and settling allowing for compression to be maintained at the arthrodesis sites throughout healing. In the first case, a 65-year-old woman with a failed total ankle replacement underwent TTC arthrodesis. The second case involved an obese 53-year-old woman who had previously undergone 2 total ankle replacement procedures that resulted in unsuccessful outcomes. In both cases, union was demonstrated on computed tomographic scan by 6 months. At 2 years postsurgery, both patients were satisfied with the procedure. These cases provide preliminary evidence that tibiotalocalcaneal arthrodesis with a pseudoelastic IM nail and structural allograft is an appropriate treatment for failed total ankle replacements. Level of Evidence: Level IV, therapeutic, case series.

Impact of Environmental Factors on Differences in Quality of Medication Use: An Insight for the Medicare Star Rating System.

BACKGROUND: The Medicare star ratings system incentivizes health plan sponsors based on their performance across a measurement system that contains quality measures related to medication use. As health plan sponsors seek to further engage their network providers, specifically network pharmacies, to improve performance on these measures, it is important to consider the effect of environmental factors on the performance of network pharmacies. OBJECTIVE: To determine the effect of environmental factors on pharmacy quality as measured by (a) medication adherence for noninsulin diabetes medications, (b) medication adherence for renin angiotensin receptor antagonists (RASA), (c) medication adherence for cholesterol medications (statins), and (d) use of high-risk medications (HRM) in the elderly. METHODS: The EQuIPP database, which contains performance information for pharmacies for a nationwide sample of Medicare beneficiaries, was used for this analysis. Environmental factors included regions or characteristics of a community or county. County-level data was obtained from the Area Health Resource Files, a resource product available from the Health Resources & Service Administration. A logistic regression model was developed with performance as the dependent variable and regions and environmental factors as independent variables. Performance and county characteristics, such as proportion of patients in an age group, race, income, or number of outpatient visits, were classified as high and low based on a median cutoff of nationwide performance scores. RESULTS: A total of 28,950 pharmacies were included in this analysis. For most measures, the proportion of low-performing pharmacies was significantly higher in the East South Central, Mid-Atlantic, Mountain, Pacific, and West South Central regions. Pharmacies in counties with high median income, high proportion of elderly population (aged > 84 years), high proportion of elderly patients who were white or Hispanic, high proportion of elderly males, and high proportion of elderly urban patients were less likely to have low performance, whereas those with high proportion of elderly African Americans and high density of independent pharmacies were more likely to have low performance (P < 0.05-0.0001). CONCLUSIONS: This study found that environmental characteristics of a region, including pharmacy and sociodemographic characteristics, explained regional variation in quality measures related to medication use for patient populations served by pharmacies. This evaluation serves to further inform the discussion regarding case-mix adjustment of quality measures and provides information that may be important to further refine intervention strategies for pharmacies and pharmacists who serve certain regional populations. Additionally, pharmacies in greatest need of support for quality improvement may be those who serve populations that are predominantly low income and elderly African American. DISCLOSURES: Desai's postdoctoral fellowship was funded by Pharmacy Quality Solutions for conducting this study and writing the manuscript. Nau and Conklin are employed by Pharmacy Quality Solutions. An earlier version of this research was presented as a poster at the Annual Meeting of the Academy of Managed Care Pharmacy; San Diego, CA; April 7-10, 2015. Study concept and design were contributed by Conklin, Nau, Desai, and Heaton. Desai and Conklin took the lead in data collection, assisted by Nau and Heaton. The manuscript was primarily written by Desai and Heaton, with assistance from Conklin and Nau. All authors contributed to data interpretation and manuscript revision.

User testing and performance evaluation of the Electronic Quality Improvement Platform for Plans and Pharmacies.

OBJECTIVE: To user-test and evaluate a performance information management platform that makes standardized, benchmarked medication use quality data available to both health plans and community pharmacy organizations. SETTING: Multiple health/drug plans and multiple chain and independent pharmacies across the United States. EVALUATION: During the first phase of the study, user experience was measured via user satisfaction surveys and interviews with key personnel (pharmacists, pharmacy leaders, and health plan leadership). Improvements were subsequently made to the platform based on these findings. During the second phase of the study, the platform was implemented in a greater number of pharmacies and by a greater number of payers. User experience was then reevaluated to gather information for further improvements. RESULTS: The surveys and interviews revealed that users found the Web-based platform easy to use and beneficial in terms of understanding and comparing performance metrics. Primary concerns included lack of access to real-time data and patient-specific data. Many users also expressed uncertainty as to how they could use the information and data provided by the platform. CONCLUSION: The study findings indicate that while information management platforms can be used effectively in both pharmacy and health plan settings, future development is needed to ensure that the provided data can be transferred to pharmacy best practices and improved quality care.

The Pennsylvania Project: pharmacist intervention improved medication adherence and reduced health care costs.

Improving medication adherence across the health care system is an ingredient that is vital to improving patient outcomes and reducing downstream health care costs. The Pennsylvania Project, a large-scale community pharmacy demonstration study, evaluated the impact of a pharmacy-based intervention on adherence to five chronic medication classes. To implement the study, 283 pharmacists from a national community pharmacy chain were assigned to the intervention group. Collectively, they screened 29,042 patients for poor adherence risk and provided brief interventions to people with an elevated risk. Compared to a control group of 295 pharmacists who screened 30,454 patients, the intervention significantly improved adherence for all medication classes, from 4.8 percent for oral diabetes medications to 3.1 percent for beta-blockers. Additionally, there was a significant reduction in per patient annual health care spending for patients taking statins ($241) and oral diabetes medications ($341). This study demonstrated that pharmacist-provided intervention is a cost-effective tool that may be applied in community pharmacies and health care sites across the country.

Pharmacy Quality Alliance: Five phase I demonstration projects: descriptions and lessons learned.

OBJECTIVES: To describe the five Phase I Pharmacy Quality Alliance (PQA) demonstration projects and discuss lessons learned across the projects. DESIGN: Descriptive nonexperimental study. SETTING: United States from July 2008 to November 2009. PARTICIPANTS: Community pharmacies from five states. INTERVENTION: Pharmacies viewed their performance scores on a reporting website and provided feedback. MAIN OUTCOMES MEASURES: Pharmacy performance scores and pharmacist feedback about the scores and reporting websites. RESULTS: Considerable variation was found in the pharmacy performance scores. Some pharmacies did not have enough patients taking medications that were included in specific performance measures. Use of a website to report pharmacy performance was feasible across several different approaches. PQA has developed measures of pharmacy performance that can be used in programs intended to report pharmacy performance. CONCLUSION: It is feasible to calculate pharmacy performance scores and create Web-based pharmacy performance reports to provide feedback to community pharmacists. Further development of pharmacy performance reporting should occur.

Case study of the effects of office-based generic drug sampling on antibiotic drug costs and first-line antibiotic prescribing ratios.

BACKGROUND: Health plans and members benefit from the substitution of lower-cost drug therapies that achieve the same clinical outcomes as higher-cost drugs. Previous research suggests that generic sampling programs produce drug cost savings overall, but the effects attributable to acute therapies are unknown. Encouraging physicians to prescribe less expensive, first-line antibiotics may help reduce direct drug costs associated with prescribing potentially unnecessary, and more expensive, second-line agents. OBJECTIVES: To determine the effects of an automated, office-based generic drug sampling kiosk on (a) prescribing of first-line oral antibiotic agents as a ratio of total antibiotic prescribing and (b) average antibiotic drug cost per claim. METHODS: This managed care organization of 2.3 million members with pharmacy benefits collaborated with a vendor that developed an automated generic drug kiosk that allows for the dispensing of samples of generic medications within the prescriber's office. Among the samples contained in the kiosk were 6 generic, first-line oral antibiotics, representing 8 unique drug-strength options. Drug costs were defined as the ingredient cost of the drug claim, which includes plan cost, member cost share, and any dispensing fees or administrative program costs associated with the sampling program. In a difference-in-difference analysis, changes in outcome measures (antibiotic drug cost per claim and dispensing rates of first-line antibiotics) from 2003 (baseline year) to 2005 (post-implementation year) were compared among kiosk prescribers (n=179) and nonkiosk prescribers who were part of the same provider network (n=7,236). A cross-sectional analysis of the same outcome measures compared kiosk (n=396) and nonkiosk prescribers (n=10,267) in 2006. All statistical analyses were performed using t-tests of logtransformed data. RESULTS: The mean cost per claim dropped by $4.14 (12.3%) from $33.56 in 2003 to $29.42 in 2005 for the kiosk prescribers and by $3.35 (8.8%) from $38.26 in 2003 to $34.91 in 2005 for nonkiosk prescribers, but the mean change from 2003 to 2005 in the difference-in-difference analysis was not statistically significant (P=0.123). The first-line antibiotic prescribing ratio declined by 2.1 absolute points from 49.1% in 2003 to 47.0% in 2005 for the kiosk prescribers and by 3.4 points from 46.0% in 2003 to 42.6% in 2005 for the nonkiosk prescribers, but the difference- in-difference analysis showed that the change was not statistically significant (P=0.901). A cross-sectional analysis of 2006 data revealed significant differences between the kiosk prescribers versus their nonkiosk network counterparts for both first-line antibiotic prescribing rates (42.0% and 41.4%, respectively; P=0.028) and antibiotic cost per claim ($28.44 and $32.40, respectively; P<0.001). While the results of the cross-sectional analysis are statistically significant, the practical significance of the results is less evident. CONCLUSIONS: The benefits of including short-term medications such as first-line antibiotics in a generic drug sampling program are difficult to quantify, and the cost outcomes are unlikely on their own to justify generic drug sampling. However, acute (short-term) medications may be an effective part of an overall program to promote generic prescribing for all conditions.

Development of a multidimensional scale to measure work satisfaction among pharmacy faculty members.

OBJECTIVES: To develop a multidimensional scale to measure work satisfaction among pharmacy faculty members and determine its reliability and validity. METHODS: A literature review was used to assist in the generation of 36 statements that putatively comprise the satisfaction construct. The 25 items meeting a priori criteria in a modified Delphi procedure were included in a questionnaire sent by e-mail to 4,228 pharmacy faculty members. Principal axis factoring and scale purification procedures were used to identify a plausible factor structure. RESULTS: Using responses acquired from 885 pharmacy faculty members, 6 domains of work satisfaction were identified: resources for scholarship, institutional support and reward, requirements for tenure and promotion, availability of a graduate program, collegiality, and teaching environment. The overall measure demonstrated construct validity, while each domain subscale exhibited relatively high internal consistency reliability. CONCLUSIONS: The overall work satisfaction measure and each subscale derived from composite domains can be used to identify sources of discontent and/or track interventions designed to improve work satisfaction.

Job turnover intentions among pharmacy faculty.

OBJECTIVES: To determine the primary reasons why pharmacy faculty intend to remain or leave their current institution and why they left their most recent academic institution, and the relative contribution of various organizational and individual characteristics toward explaining variance in turnover intentions. METHODS: A survey instrument was e-mailed to pharmacy faculty members asking respondents to indicate up to 5 reasons for their intentions and up to 5 reasons why they left a previous institution. The survey also elicited perceptions on quality of work life in addition to demographic and institutional data, upon which turnover intentions were regressed using a forward-conditional procedure. Organizational commitment as a moderator of turnover intentions was regressed over the remaining variables not acting directly on employer intentions. RESULTS: Just over 1 in 5 respondents indicated intentions to leave their current academic institution. Excessive workload, seeking a new challenge, poor salary, and poor relationships with college or school administrators were frequently cited as reasons for leaving. Turnover intentions are influenced directly by department chair support and organizational commitment, which moderates various support and satisfaction variables. CONCLUSIONS: Pharmacy faculty members' decision to remain or leave an institution is dependent upon developing a sense of commitment toward the institution. Commitment is facilitated by support from the institution and department chair, in addition to a sense of satisfaction with the teaching environment.