Frequency to Non-Compliance to Oral Iron Therapy in Pregnancy and Common Factors Leading to it

OBJECTIVES: The objective of this study was to determine frequency of non-compliance to oral iron therapy in pregnancy and common factors leading to it. METHODOLOGY: It was a cross-sectional study done in the Department of Obstetrics and Gynecology of Lady Willington Hospital Lahore, Pakistan. The duration of this study was six months i.e., 3rd October 2019 to 2nd March 2020. All antenatal patients between ages of 18 to 45 years presented in the obstetrics outdoors or admitted in the ward were included in this study. A total of 245 patients were included in this study by consecutive non-probability sampling. Patients with gynecological problems, patients dependent on others for their medication cost, patients with psychiatric illness or physical disability were excluded. Post stratification Chi-square test was applied keeping P-value ≤0.05 as significant RESULTS: Among 245 patients, mean age was 27±2.16 years. Iron supplement used by 245 patients was analyzed as 159 (65%) patients had used the iron supplement while 86 (35%) patients didn’t use iron supplements (P-value 0.001). Iron supplement used by 245 patients was analyzed and only 93 (38%) patients had used the iron supplement while 152 (62%) patients didn’t use iron supplements. CONCLUSION: The coverage of antenatal iron and folic acid supplements is very low in the surveyed districts of Pakistan due to lack of parental education and older aged women belonging to poor households.

Analysis of Housing Risk Factors for the Welfare of Lean and Heavy Pigs in a Sample of European Fattening Farms

Pig welfare is affected by housing conditions, the minimum requirements of which are set up by EU legislation. Animal and non-animal-based measures are useful indicators to investigate housing risk factors for pig welfare. An observational study on 51 pig farms in seven EU countries, aimed at investigating housing risk factors for the welfare of finishing pigs, showed body weight and presence of bedded solid floored resting area (BED) identifying three clusters of farms. Farms with BED were featured by no or limited tail docking, larger availability of manipulable materials and lower number of pigs per farm and per annual work unit. In these farms, less skin and ear lesions were found, compared with lean pigs of farms without BED, which were characterized by lower pig space allowance, mortality rate and medication cost. In farms without BED, heavy pigs were featured by more space per pig, more pigs per drinker and higher mortality rate and medication cost per pig, compared to lean pigs. No statistical difference in tail lesions was found between the three farm clusters, although tail docking was performed in all farms without BED and not performed on most farms with BED.

98. Outcomes of Clinical Decision Support for Outpatient Management of Clostridioides difficile Infection

Background Our antimicrobial stewardship program identified high rates of suboptimal metronidazole prescribing for Clostridioides difficile infection (CDI) within ambulatory clinics. An outpatient best practice advisory (BPA) was implemented to notify prescribers “Vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection” when metronidazole was prescribed to a patient with CDI. Methods We conducted an IRB approved quasi-experiment before and after implementation of the BPA on June 3, 2020. Inclusion: Adult patients diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between 11/1/2019 and 11/30/2020. Exclusion: fulminant CDI. Primary endpoint: guideline-concordant CDI therapy, defined as oral vancomycin or fidaxomicin. Oral metronidazole was considered guideline-concordant if prescribed due to cost barrier. Secondary endpoints: reasons for alternative CDI therapy, patient outcomes, prescriber response to the BPA. Descriptive and bivariate analyses were completed. Results 189 patients were included in the study, 92 before and 97 after the BPA. Median age: 59 years, 31% male, 75% Caucasian, 30% with CDI-related comorbidities, 35% with healthcare exposure, 65% with antibiotic exposure, 44% with gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 out of 26 times and optimized the therapy of 16 patients in six months. Guideline-concordant therapy increased after implementation of the BPA (72% vs. 91%, p=0.001) (Figure 1). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA (Figure 2). Reasons for alternative CDI therapy included medication cost, lack of insurance coverage, and non-CDI infection. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs. 7%, p< 0.001). Figure 1. Guideline-concordant CDI therapy Figure 2. Specific CDI therapy Conclusion Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources. Disclosures Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

Applying the Social-Ecological Approach to Evaluate Diabetes Medication Management in Older People

Glucagonlike peptide-1 receptor agonist is a common antidiabetic medication class to lower HbA1c, weight, and cardiovascular risk. This case study describes the challenges a patient with uncontrolled diabetes faced after receiving a prescription for liraglutide because of multiple levels of influence, including individual, family, institutional, and policy level barriers. The case highlights the importance of utilizing a person-centered care approach by evaluating patient's preferences, visual and motor coordination, cognitive function, psychological stress, and medication cost before prescribing injectable products for elderly patients.

Use of Traditional Chinese Medicine and Its Impact on Medical Cost among Urban Ischemic Stroke Inpatients in China: A National Cross-Sectional Study

Background. Traditional Chinese medicine (TCM) has long been widely adopted by the Chinese people and has been covered by China’s basic medical insurance schemes to treat ischemic stroke. Previous research has mainly highlighted the therapy effect of TCM on ischemic stroke patients. Some studies have demonstrated that employing TCM can reduce the medical burden on other diseases. But no research has explored whether using TCM could reduce inpatient medical cost for ischemic stroke in mainland China. The purpose of this study is to investigate the impact of the use of TCM on the total inpatient cost of ischemic stroke and to explore whether TCM has played the role of being complementary to, or an alternative for, conventional medicine to treat ischemic stroke. Methods. We conducted a national cross-sectional analysis based on a 5% random sample from claims data of China Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) schemes in 2015. Mann–Whitney test was used to compare unadjusted total inpatient cost, conventional medication cost, and nonpharmacy cost estimates. Ordinary least square regression analysis was performed to compare demographics-adjusted total inpatient cost and to examine the association between TCM cost and conventional medication cost. Results. A total of 47321 urban inpatients diagnosed with ischemic stroke were identified in our study, with 92.6% (43843) of the patients using TCM in their inpatient treatment. Total inpatient cost for TCM users was significantly higher than TCM nonusers (USD 1217 versus USD 1036, P < 0.001 ). Conventional medication cost was significantly lower for TCM users (USD 335 versus USD 436, P < 0.001 ). The average cost of TCM per patient among TCM users was USD 289. Among TCM users, conventional medication costs were found to be positively associated with TCM cost after adjusting for confounding factors (Coef. = 0.144, P < 0.001 ). Conclusion. Although the use of TCM reduced the cost of conventional medicine compared with TCM nonusers, TCM imposed an extra financial component on the total inpatient cost on TCM users. Our study suggests that TCM mainly played a complementary role to conventional medicine in ischemic stroke treatment in mainland China.

An electronic tool for health systems to assess and communicate discharge medication access

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge. Summary Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board–approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge. Conclusion The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system.

REDUCTIONS IN MEDICATION WASTAGE AND COSTS IN A PEDIATRIC INTENSIVE CARE UNIT BY CHANGING THE ORDER ENTRY SYSTEM

Objective: The intensive care unit (ICU) drug therapies have a significant impact on hospital costs, and reducing these costs has become a critical concern for hospitals. In this study, the researchers tested the theory on whether changing the ordering system of medications in the pediatric ICU (PICU)1, reduces drug wastage so that the nurse can request a fraction of one vial or ampule. More precisely, the study aimed to reduce the medication cost and wastage in our pediatric center. Methods: This study was conducted in the 16-bed PICU of Imam Hossein Hospital, which is a referral tertiary care teaching pediatric hospital with 185 beds in ten wards. A fractional ordering alternative was added to the hospital information system of the PICU of the pediatric hospital. Nurses were taught by the hospital pharmacist to understand the new way of ordering the drugs. Several highly used drugs were chosen for the intervention. The data were analyzed by an independent sample t-test using SPSS software. Results: Based on the results, changing the method of requesting medications for PICU patients and the random checking of floor stocks and the expired drugs in PICU reduced the number and cost of all medications. Conclusion: Overall, the collaboration of nurses and pharmacists can lead to cost savings in hospitals.

Chyavanprash: A Multimodal Approach to COVID-19 Management

The word Chyavanprash (CP) comprises of ‘Chyawan’ and ‘Prasha’. Chyavan represents ‘degenerative change’ and Prasha symbolises a drug. Enhancement of immunity and longevity of life were the main reasons for which CP was consumed since ancient times. CP has about 50 herbs, spices and minerals along with a range of pharmacological activities on almost all organ systems of the human body. COVID-19 actually means coronavirus disease 2019. COVID-19 targets and affects multiple organs like lungs, heart, kidney etc, thus increasing the mortality and morbidity rates. The medication cost and side effects have made the allopathic system of medicine the least sought after. The rapid spread rate of the infection has urged mankind to look at alternative remedies to fight the novel coronavirus. AYUSH is a government organisation under the Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy which aims to promote indigenous alternative medicine systems in India. AYUSH recommends various measures to fight the novel coronavirus infection. Chyavanprash is one such important formulation proposed by the AYUSH for COVID-19. The purpose of our review is to highlight the constituents and pharmacological activities of CP in the prophylaxis, manage and treatment of COVID-19 by collecting and compiling the published research on COVID-19. The review also focuses on understanding the mechanism behind the multimodal activity of CP. References relevant to our topic were screened based on relevance to our topic.

86Segmenting persistently high-cost individuals into actionable groups

Background Despite growing evidence describing high cost patients, decision-makers struggle to implement effective strategies to improve care and curb spending in this population. Using a multi-phased approach, we aimed to classify high cost patients into homogeneous subgroups amenable to targeted interventions. Methods We linked population-level administrative health data in Alberta, Canada from 2012-2017. We defined “persistently high-cost” as those in the top 1% of cumulative inpatient, outpatient and medication cost in at least two consecutive years. We used latent class analysis to separate this persistent high-cost population into potentially actionable subgroups. Results Of the 3,795,067 adults residing in Alberta, 21,361 were ‘persistently high-cost’. Latent class models identified 10 high-cost subgroups: individuals with CKD (19.3% of persistent high-cost individuals), those undergoing joint surgery/replacement and rehabilitation (18.6%), individuals with IBD (11.6%), patients receiving biologics for autoimmune conditions (11.3%), patients receiving high cost drugs for other conditions (11.1%), community-dwelling individuals with multimorbid chronic conditions (9.0%), individuals with schizophrenia (6.8%), individuals with other mental health issues (6.2%), rural individuals with COPD (3.4%), and frail elderly in institutional settings (2.7%). Conclusions Latent class analysis was able to identify 10 persistently high-cost groups based on meaningful differences in health care spending, demographics, and clinical diagnoses. Key messages This taxonomy will inform the identification of interventions shown to improve care and reduce cost for each subgroup in addition to consultation with key stakeholders to identify and reflect on key barriers and facilitators to implementing identified interventions within the local context.