Impact of Pharmacy Services on Time to Elexacaftor-Tezacaftor-Ivacaftor Initiation

The approval of elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) expanded highly effective cystic fibrosis transmembrane receptor modulator therapy to approximately 90% of persons age 12 and older with cystic fibrosis. Clinical pharmacists and pharmacy technicians played a key role in planning for ELX/TEZ/IVA initiation prior to FDA approval as well as initiating therapy after approval. This study evaluates the impact of pharmacy services on time to ELX/TEZ/IVA initiation. A retrospective chart review evaluated patients qualifying for ELX/TEZ/IVA at a single health system between October 21, 2019 and April 1, 2020. Patients filling ELX/TEZ/IVA at an integrated health system specialty pharmacy (HSSP) versus an outside specialty pharmacy (SP) started on therapy an average of 10.8 days faster (10.8 days ± 14.0 vs 21.6 days ± 18.8 respectively; p=0.006). More patients filling at a HSSP received ELX/TEZ/IVA within 14 days of the prescription being written compared to outside SPs (82.0% vs 41.4% respectively; p=0.001). Pre-ELX/TEZ/IVA initiation, patients were hospitalized for a CF related complication for an average of 6.26 days (range 0-183) compared to 1.16 days (range 0-91) post-ELX/TEZ/IVA initiation. Lastly, an estimated $134,810 was saved in the 105 patients that were able to fill ELX/TEZ/IVA at a HSSP by initiating drug an average of 10.8 days quicker than outside SPs. The results of this study demonstrate the value of an integrated HSSP model. Further advocacy for inclusion of integrated HSSPs by pharmacy benefit managers is needed to optimize medication access, control costs, and improve patient outcomes for patients receiving care within a health system.

Does Money Matter? Characteristics Associated With Joint Pain Medication Access Among Older Adults

The experience of pain is a widespread phenomenon among adults, especially older adults, and entails high costs to both individuals and society. The objective of the current research is to determine if the ability to pay and supplementary insurance are factors associated with pain medication among individuals over 50. Data came from Survey of Health, Aging and Retirement in Europe (SHARE). The sample included 64,281 individuals 50+ from nineteen European countries and Israel. Joint pain was common with one out of three reporting joint pain. Prevalence of pain was similar among different age groups, and more women reported joint pain. Among those in pain, about 21.5% of the individuals reported mild pain, 52.9% moderate and 26% severe pain. In the multivariate logistic regression, we found that men and those older than 60 suffered more from joint pain, while controlling for education and subjective assessment of the ability to cope economically (Able to make ends meet). A large percentage of those with pain were not taking medication to manage their pain, and there were significant demographic differences between those that did and did not take medication. Those that took medication were younger, male, had more education, were able to cope economically and had supplementary insurance. Our study showed that about half of the individuals with pain were not taking medication to manage their pain. Our results demonstrate that among individuals over 50 in Europe income is strongly associated with taking pain medication and that there is economic inequity in medication access.

887. Implementation of Long-acting Injectable Cabotegravir/Rilpivirine for HIV-1 Treatment at a Ryan White-funded Clinic in the U.S. South

Background In January 2021, the first ever long-acting injectable (LAI) antiretroviral therapy (ART), cabotegravir/rilpivirine (CAB/RPV), was approved for maintenance HIV-1 treatment in select patients with virologic suppression. LAI-ART has the potential to improve ART adherence, reduce HIV stigma, and promote equity in care outcomes, however, implementation in real-world settings has yet to be evaluated. Methods We launched a pilot LAI-ART program at the largest Ryan White-funded HIV clinic in the Southeast. From 4/14/21 to 5/14/21, providers referred patients interested and willing to switch to LAI-CAB/RPV who met screening criteria. Our interdisciplinary LAI team (Clinician-Pharmacy-Nursing) verified clinical eligibility (HIV-1 < 200 c/ml ≥6 months and no history of virologic failure, resistance to either drug, or chronic HBV infection) and pursued medication access for 28-day oral lead-in and monthly injectable CAB/RPV. We describe demographic and clinical variables of referred PWH and early outcomes in accessing LAI-ART. Results Among 42 referrals, median age was 40.5 (Q1-Q3, 32-52) years, 83% were men, and 76% Black. Payor source distribution was 26% Private, 19% Medicare, 10% Medicaid, and 45% ADAP. At the time of referral, median CD4 count was 583 (Q1-Q3, 422-742) cells/mm3 and median sustained HIV-1 RNA < 200 c/ml was 1427 (Q1-Q3, 961-2534) days. A total of 35 patients (74%) met clinical eligibility for LAI-CAB/RPV, including 4 patients who required a transition off proton pump inhibitor therapy to accommodate oral RPV. Ineligible PWH were excluded due to evidence of RPV resistance (n=5), possible RPV hypersensitivity (n=1), and HIV non-suppression (n=1). The table summarizes the process of pursuing LAI-ART access for the initial 10 enrollees by insurance status. Conclusion Our experience implementing LAI-ART at a Ryan White-funded HIV clinic in the Southern U.S. has been challenged by substantial human resource capital to attain drug, delayed therapy initiation due to insurance denials, and patient ineligibility primarily due to concern for potential RPV resistance. These barriers may perpetuate disparities in ART access and virologic suppression among PWH and need to be urgently addressed so that LAI-ART can be offered equitably. Disclosures Lauren F. Collins, MD, MSc, Nothing to disclose Bradley L. Smith, Pharm.D., AAHIVP, Gilead Sciences, Inc (Advisor or Review Panel member) Wendy Armstrong, MD, Nothing to disclose Jonathan Colasanti, MD, Integritas CME (Consultant, develop and deliver CME content around Rapid Entry/Rapid ART)

157. Impact of Pharmacist-Generated Oral Antimicrobial Test Prescription on Discharge Medication Access and Outcome

Background Cost barriers to accessing discharge oral antimicrobials (ABX) may delay discharges and result in suboptimal discharge ABX. Use of electronic test prescriptions (eTP) or “price checks” is controversial due to potential for erroneous dispensing. This study evaluated discharge ABX access and outcome after implementation of a standardized, inpatient pharmacist-initiated ABX eTP process in collaboration with discharge pharmacy. Methods IRB approved, retrospective, cross-sectional cohort pilot-study. Inclusion: home bound adults admitted for ≥ 72 hours from 1/1/18-2/28/19 and discharged on oral ABX. Patients with an ABX eTP prior to discharge were compared to those discharged on ABX but no eTP. Data were reported using descriptive statistics and bivariate analysis. Primary endpoint: discharge delay after medical stability. Secondary endpoints: medication access, unplanned encounters, and % of patients discharged on first-line ABX. Results 84 patients included: 43 no-ETP and 41 eTP. 75 ABX eTP evaluated among 41 patients. Patients in the no-eTP group had higher Charlson comorbidity index (P = 0.004) and immunosuppression (24% vs. 12%; P = 0.014). Median length of stay, days: 6 (5 – 9) eTP vs. 8 (5 – 15) no-eTP (P = 0.026). Most common eTP requested by pharmacist: linezolid (17, 23%) and oral vancomycin (12, 16%) (Figure 1). eTP results were documented in the medical record in < 24 hours for 66 (88%) of inquiries. 49 (65%) prescriptions were approved by insurance; 16 (21%) had no out of pocket cost and 8 (11%) required prior authorization (PA) (Table 1). Linezolid (5, 35%) and public insurance (10, 71%) were frequently associated with barriers. 29 (70%) patients were discharged on the same ABX as the eTP. There were no discharge delays or erroneous dispensing. 14 (33%) no-eTP and 15 (37%) eTP patients experienced unplanned healthcare encounters after discharge. 9/84 (11%) patients were discharged on suboptimal ABX. Non-white race 8/9 (89%) P = 0.047 and public insurance 8/9 (89%) P = 0.063 were associated with suboptimal discharge ABX. Figure 1. Oral Antimicrobial Test Prescription Pattern (n=75) Table 1. Oral Antimicrobial Test Prescription Result (n=75) Conclusion A standardized eTP process appears to be a safe way to evaluate out of pocket cost without prolonging length of stay. Future work will focus on inequity in access to first line ABX. Disclosures Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

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.

Pre-pandemic mental health and disruptions to healthcare, economic and housing outcomes during the COVID-19 pandemic: evidence from 12 UK longitudinal studies

Background The COVID-19 pandemic has disrupted lives and livelihoods, and people already experiencing mental ill health may have been especially vulnerable. Aims Quantify mental health inequalities in disruptions to healthcare, economic activity and housing. Method We examined data from 59 482 participants in 12 UK longitudinal studies with data collected before and during the COVID-19 pandemic. Within each study, we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to healthcare (medication access, procedures or appointments), economic activity (employment, income or working hours) and housing (change of address or household composition). Estimates were pooled across studies. Results Across the analysed data-sets, 28% to 77% of participants experienced at least one disruption, with 2.3–33.2% experiencing disruptions in two or more domains. We found 1 s.d. higher pre-pandemic psychological distress was associated with (a) increased odds of any healthcare disruptions (odds ratio (OR) 1.30, 95% CI 1.20–1.40), with fully adjusted odds ratios ranging from 1.24 (95% CI 1.09–1.41) for disruption to procedures to 1.33 (95% CI 1.20–1.49) for disruptions to prescriptions or medication access; (b) loss of employment (odds ratio 1.13, 95% CI 1.06–1.21) and income (OR 1.12, 95% CI 1.06 –1.19), and reductions in working hours/furlough (odds ratio 1.05, 95% CI 1.00–1.09) and (c) increased likelihood of experiencing a disruption in at least two domains (OR 1.25, 95% CI 1.18–1.32) or in one domain (OR 1.11, 95% CI 1.07–1.16), relative to no disruption. There were no associations with housing disruptions (OR 1.00, 95% CI 0.97–1.03). Conclusions People experiencing psychological distress pre-pandemic were more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening mental health inequalities.