Management of Newer Medications for Attention-Deficit/Hyperactivity Disorder in Commercial Health Plans

PurposeIn the United States, many individuals with attention-deficit/hyperactivity disorder (ADHD) pay for their medications using private health insurance coverage. As in other drug classes, private insurers are actively seeking to influence use and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients’ access to medications. This article examines approaches (eg, copayments, prior authorization, and step therapy) that commercial health plans are using to manage newer medications used to treat ADHD and changes in approaches since 2003.MethodsData are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse, and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of 6 branded ADHD medications, respondents were asked whether the plan covered the medication and, if so, on what copayment tier each medication was placed and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.FindingsThere was considerable variation across these 6 medications in how tightly they were managed by health plans, with newer medications being subject to more stringent management. The proportion of insurance products relying solely on copayment tiering to manage new ADHD medications appears to have decreased since 2003. Less than half of insurance products (43%) managed these 6 medications solely by use of tier 3 or 4 placement, and most of the remainder (48%) used other restrictions (with or without tier 3 or 4 placement). The average insurance product restricted access to at least 3 of the 6 brand-only medications examined, whether through copayment tier placement or other approaches. More ADHD medications were left unrestricted in health maintenance organization products than in preferred provider organization ones, products with internal or hybrid-internal contracts for behavioral health, those not contracting with pharmacy benefits managers, and those with for-profit ownership.ImplicationsMany plans have supplemented copayment tiering with other approaches, such as prior authorization and step therapy, to influence use and decrease costs. It may be that plans have found copayments to be less effective in redirecting use in this medication class. The effect on clinical outcomes was not examined in this study but should be prioritized using other data sources.     

Challenges of self-management when living with multiple chronic conditions: Systematic review of the qualitative literature

ObjectiveTo explore the perspectives of patients who live with multiple chronic conditions as they relate to the challenges of self-management.SynthesisImportant themes raised by people living with multiple chronic conditions related to their ability to self-manage included living with undesirable physical and emotional symptoms, with pain and depression highlighted. Issues with conflicting knowledge, access to care, and communication with health care providers were raised. The use of cognitive strategies, including reframing, prioritizing, and changing beliefs, was reported to improve people’s ability to self-manage their multiple chronic conditions.ConclusionThis study provides a unique view into patients’ perspectives of living with multiple chronic conditions, which are clearly linked to common functional challenges as opposed to specific diseases. Future policy and programming in self-management support should be better aligned with patients’ perspectives on living with multiple chronic conditions. This might be achieved by ensuring a more patient-centred approach is adopted by providers and health service organizations.     

Everyday memory strategies for medication adherence

The need to manage chronic diseases and multiple medications increases for many older adults. Older adults are aware of memory declines and incorporate compensatory techniques. Everyday memory strategies used to support medication adherence were investigated. A survey distributed to 2000 households in the Atlanta metropolitan area yielded a 19.9% response rate including 354 older adults, aged 60–80 years. Older adults reported forgetting to take their medications, more so as their activity deviated from normal routines, such as unexpected activities. The majority of older adults endorsed at least two compensatory strategies, which they perceived to be more helpful in normal routines. Compensatory strategies were associated with higher education, more medications, having concern, and self-efficacy to take medications. As memory changes, older adults rely on multiple cues, and perceive reliance on multiple cues to be helpful. These data have implications for the design and successful implementation of medication reminder systems and interventions.     

The Impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses

It is a challenge for rural health professionals to promote medication safety among older adults taking multiple medications. A volunteer coaching program to promote medication safety among rural elders with chronic illnesses was designed and evaluated. A community-based interventional study randomly assigned 62 rural elders with at least two chronic illnesses to routine care plus volunteer coaching or routine care alone. The volunteer coaching group received a medication safety program, including a coach and reminders by well-trained volunteers, as well as three home visits and five telephone calls over a two-month period. All the subjects received routine medication safety instructions for their chronic illnesses. The program was evaluated using pre- and post-tests of knowledge, attitude and behaviors with regard to medication safety. Results show the volunteer coaching group improved their knowledge of medication safety, but there was no change in attitude after the two-month study period. Moreover, the group demonstrated three improved medication safety behaviors compared to the routine care group. The volunteer coaching program and instructions with pictorial aids can provide a reference for community health professionals who wish to improve the medication safety of chronically ill elders.     

Patterns of Symptom Management Medication Receipt at End-of-Life Among Medicare Beneficiaries With Lung Cancer

ContextOlder adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described.ObjectivesWe examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer.MethodsThis retrospective cohort used the Surveillance, Epidemiology, and End Results—Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy.ResultsOf the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities.ConclusionSymptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.     

Risks of combined alcohol/medication use in older adults

Background:Many older adults (ie, those aged ≥65 years) drink alcohol and use medications that may be harmful when consumed together.Objective:This article reviews the literature on alcohol and medication interactions, with a focus on older adults.Methods:Relevant articles were identified through a search of MEDLINE and International Pharmaceutical Abstracts (1966–August 2006) for English-language articles. The following medical subject headings and key words were used: alcohol medication interactions, diseases worsened by alcohol use, and alcohol metabolism, absorption, and distribution. Additional articles were identified by a manual search of the reference lists of the identified articles, review articles, textbooks, and personal reference sources.Results:Many older adults drink alcohol and take medications that may interact negatively with alcohol. Some of these interactions are due to age-related changes in the absorption, distribution, and metabolism of alcohol and medications. Others are due to disulfiram-like reactions observed with some medications, exacerbation of therapeutic effects and adverse effects of medications when combined with alcohol, and alcohol's interference with the effectiveness of some medications.Conclusions:Older adults who drink alcohol and who take medications are at risk for a variety of adverse consequences depending on the amount of alcohol and the type of medications consumed. It is important for clinicians to know how much alcohol their older patients are drinking to be able to effectively assess their risks and to counsel them about the safe use of alcohol and medications. Similarly, it is important for older adults to understand the potential risks of their combined alcohol and medication use to avoid the myriad of problems possible with unsafe use of these substances.     

Medication adherence among geriatric outpatients prescribed multiple medications

BackgroundPoor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outcomes.ObjectiveWe aimed to determine the prevalence and correlates of PMA in an older population with polypharmacy.MethodsBaseline data from 193 older adults from the Medication Safety Review Clinic Taiwan Study were analyzed. Patients were either prescribed ≥8 long-term medications or visited ≥3 different physicians between August and October 2007. PMA was defined as taking either <80% or >120% of prescribed amounts of a medication. Patients were classified as no (0%), low level (>0 but <25%), and high level (≥25%) PMA depending on what percentage of entire medication regimen taken reached PMA.ResultsMean (SD) age was 76 (6) years, and mean number of medications was 9 (3), with a mean medication class number of 4 (1). Of the 1713 medications reviewed, 19% had PMA. However, at patient level, 34%, 32%, and 34% of patients were classified as no, low level, and high level PMA, respectively. Correlates varied by levels of PMA. Compared with patients without PMA, higher medication class number and use of alimentary tract, psychotropic, and hematologic agents were associated with both low and high level PMA. History of dizziness was associated with low level PMA, and higher Mini Mental Status Examination score was associated with high level PMA.ConclusionsTo enhance medication adherence in older adults prescribed multiple medications, medication class numbers and certain high-risk medication classes should be taken into account. Physicians should also routinely assess systemic (eg, cognition) or drug-specific characteristics (eg, side effects).     

An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial

Patients with type II diabetes often struggle with self-care, including adhering to complex medication regimens and managing their blood glucose levels. Medication nonadherence in this population reflects many factors, including a gap between the demands of taking medication and the limited literacy and cognitive resources that many patients bring to this task. This gap is exacerbated by a lack of health system support, such as inadequate patient–provider collaboration. The goal of our project is to improve self-management of medications and related health outcomes by providing system support. The Medtable? is an Electronic Medical Record (EMR)-integrated tool designed to support patient–provider collaboration needed for medication management. It helps providers and patients work together to create effective medication schedules that are easy to implement. We describe the development and initial evaluation of the tool, as well as the process of integrating it with an EMR system in general internal medicine clinics. A planned evaluation study will investigate whether an intervention centered on the Medtable? improves medication knowledge, adherence, and health outcomes relative to a usual care control condition among type II diabetic patients struggling to manage multiple medications.     

Negotiating medications: patient perceptions of long-term medication use

OBJECTIVE: To investigate how adults with one of several chronic illnesses (bipolar disorder, multiple sclerosis, rheumatoid arthritis, schizophrenia/schizoaffective disorder, or systemic lupus erythematosus) perceive their need to take medications during the course of their illness. METHOD: Eighty-three adults, aged 18-64 years, all members of a health maintenance organization, were interviewed. Each participant completed an ethnographic interview that was transcribed verbatim and analysed using grounded theory techniques. RESULTS: Participants described two forms of ongoing efforts to negotiate their need for medications, internal and external. The former category includes struggles over self-identify (e.g. worries about becoming dependent on drugs, feeling like a 'guinea pig'). The latter includes negotiations with health care providers over the type, route, and frequency of medication use. Dimensions of both negotiation types include acceptance and resistance. Specifically, patients with chronic illness must manage not only drug regimens, but also renegotiate their self-identities as formerly well persons. During this dynamic process, patients may accept and/or resist taking prescribed medications. CONCLUSION: Practitioners should recognize that patients experience not only physical, but emotional side effects of medications, and that resistance might be part of a negotiation process rather than a final stance.     

Methodology of a pilot study to improve the quality of medication use in older adults: Enhancing quality in psychiatry using pharmacists (EQUIPP)

Background: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increased risk because of their underlying disease and types of medications prescribed. Efforts to improve the quality of medication use often focus on select medication-related problems, select diagnoses, or predefined quality indicators; however, such an approach fails to consider the potential for multiple coexisting problems within individuals.Objective: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. This article describes the methodology of the study and details of the intervention, and presents baseline characteristics of the study population.Methods: English-speaking psychiatry outpatients aged ≥65 years taking ≥2 drugs that are active in the central nervous system were enrolled into a medication management program, in which medication management was provided by a clinical pharmacist for 6 months. Patients were evaluated at baseline, 3 months, and 6 months. Data were collected on the patients' demographic characteristics, health and medications, health literacy, functional status, symptoms of depression, health services utilization, quality of medication use, adherence, and patient satisfaction with the program.Results: One hundred seventy-three older adults were assessed for inclusion; 146 were not eligible, not reachable, or not interested in participating. Twenty-seven older adults were enrolled in the study, all but one of whom completed the 3- and 6-month visits. The mean (SD) age of the 27 participants was 74.7 (8.1) years; 63% were female, 74% were white, and 70% had no cognitive impairment.Conclusions: This pilot study tested the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. Findings from this study, which will be reported at a later date, will help to refine the program and subsequent testing, with the overall goal of improving the quality of medication use and health outcomes in older adults.     

Medication safety challenges in the palliative care setting: Nurses' perspectives

AimTo explore medication safety issues faced by general and palliative care community nurses working in rural and remote palliative care domiciliary settings.MethodAn online survey for nurses working in rural communities was conducted across the South East region of rural Victoria, Australia. Nurses from 18 community based health care organisations across the region were invited to participate in an anonymous survey addressing medication safety issues in the palliative care settings. Qualitative data obtained from the open-ended survey questions were analysed inductively.ResultsA total of 29 nurses completed the survey (response rate 28% from potential respondents). Most of the nurses were working in a rural practice providing a mixed model of community palliative care and community nursing. Medication safety issues raised by the nurses included; errors associated with dose administration aids, frequency of medications reviews undertaken by clinical pharmacists of clients’ medications, high occurrence of medications error reporting, lack of awareness of medications initiated by nurses and cytotoxic medications handling.ConclusionTargeted interventions addressing the identified issues raised by community general and palliative care nurses have the potential to improve medication safety in the domiciliary palliative care setting.     

Barriers and Facilitators of Pain Self-Management Among Patients with Cancer: An Integrative Review

BackgroundDefining the main barriers and facilitators of cancer pain self-management are essential to improve patients’ overall quality of life.AimThe main purpose of this review was to identify the main barriers and facilitators for cancer pain self-management.MethodAn integrative review guided by the five-stages framework that was identified by Souza et al. (2010) was used: (1) preparing the guiding question; (2) searching or sampling the literature; (3) data collection; (4) critical analysis of the studies; and (5) discussion of results. A comprehensive literature review was conducted using the electronic databases of PubMed/MEDLINE, CINAHL, Scopus, and Psych INFO.ResultsTwenty-two studies were identified. The main facilitators that foster the process of cancer pain self-management were supportive ambiances including family caregivers as well as health care providers, active participation of patients with cancer in health care including self-discovery and self-awareness, acquiring pain knowledge, and using a pain diary. The main barriers include concerns regarding the use of pain medications, knowledge deficit, negative beliefs and attitudes, unsupportive ambiance, and psychological distress. Some patients’ characteristics could be related to these barriers such as age, sex, race, marital status, educational level, level of pain, and presence of comorbidity.ConclusionsPatients with cancer pain experience multiple barriers and facilitators when attempting to take on an active role in managing their pain.