Clinical Pharmacy Services & ADAP Clients

1. Clinical Pharmacy Services & ADAP Clients Stephen Berk, RPh Acting Chief California AIDS Drug Assistance Program Unit

3. Clinical Pharmacy versus Pharmacy • Pharmacy • Attention is on the drug • Clinical Pharmacy • Attention is on the patient or population receiving the drug

4. Traditional Pharmacy

5. Clinical Pharmacy

6. Attention to patient or population receiving the medications • Maximizing the clinical effect of medicines • Using the right medication at the right time • Minimizing the risk of adverse events • Educate about possible side effects • Monitor and improve adherence • Preserve scarce resource dollars • Less resistant virus • Less opportunistic infections • Possibly less side effects requiring additional therapy

7. Why Clinical Pharmacy Services • Benefit to the Client • Benefit to the Program • Benefit to Society

8. Benefits of Service • Several studies indicate client – society benefits • Journal of the American Pharmacists Association (APhA) 2008 • Aetna presentation at Academy of Manage Care Pharmacy Meeting 2008 • Kaiser study in J. Acquired Immune Deficiency Syndrome 2007

9. APhA • Clients with multiple medical conditions and complex drug therapies • Significant improvement in drug therapy goals achieved • Drug problems resolved • Total annual health expenditures decreased

10. Aetna Study • 2,400 clients identified as candidates for an adverse drug event – not disease specific • 15% drop in adverse drug events • Cost avoidance ranged from $476 to $2,506 per patient per year • Low touch intervention • Letter to prescriber • High touch intervention • Phone call to prescriber

11. Kaiser Study • Observational Study with two arms (1571 clients) • (A) sites with HIV trained pharmacist • (B) sites without HIV trained pharmacist • Outcomes Analyzed • Changes in plasma HIV RNA level • CD4 T-cell counts • Service utilization • Hospital days, ED visits, and office visits

12. Kaiser Study • Results • Clients exposed to clinical pharmacist more likely to achieve HIV RNA level < 500 copies/mL at 12 months • At 24 months, practice size impacted results • Practices with >50 clients less impacted by clinical pharmacist • CD4 T-cell counts not significantly affected

13. Kaiser Study • Conclusions • Positive association between clinical pharmacist and plasma HIV RNA control • Decline in office visits at 12 months • Limitations • Did not document interventions • Did not analyze impact on health care costs

14. Medi-Cal HIV Pharmacy Pilot • 10 HIV Specialty Pharmacies • 4 pharmacies from one organization • Reimbursed additional $9.50 per prescription • Measure results of specialized services

15. Medi-Cal HIV Pharmacy Pilot • Services Offered • Evaluation of clients ability to adhere - 7 • Identify & manage adverse drug reactions - 7 • Management of side effects - 7 • Tailor drug regimen to fit clients lifestyle - 6 • Individualized counseling when overuse or under use is detected -6

16. Medi-Cal HIV Pharmacy Pilot • Services offered • Refill reminders - 5 • Individual appointments with pharmacist - 4 • Adherence packaging - 4 • Peer advocates - 4 • Home visits or weekly phone call - 4 • Other health assessments (blood pressure) - 4 • Medication reminders (pagers, alarms) -3

17. Medi-Cal HIV Pharmacy Pilot • First year evaluation (UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences) • Higher medication adherence rates • Fewer excess fills • Fewer contraindicated regimens • More clients remained on single type ART strategy throughout 2005

18. California ADAP

19. California ADAP

20. California ADAP

21. Clinical Services in California • Relatively New • Quarterly Clinical Update for Pharmacies • Pipeline Medications • Recent Approvals • Adherence Tips • Review of Prescription Claims • Duplicate Therapy • Drug Interactions • Contraindications

22. Clinical Services in California • New Drug Pipeline Monitoring • Determine Place in Therapy • Estimate Price • Project Usage • Clinical Drug Information for Medical Advisory Committee • Criteria for Medication Use • Input from PBM • Input from Medical Advisory Committee

23. California ADAP • Future Plans • Pharmacy visits? • Partner with AETC • Pharmacist education ? • Use of ADAP Claims Data for Adherence Monitoring • Medication Therapy Management • Reimbursement ?

24. California Limitations • Staff • Unit Chief’s (Pharmacist) Time Spent Doing Administrative Duties • Need to Hire Pharmaceutical Consultant • Need Research Staff to do Data Mining • Knowledge Level of Dispensing Pharmacies • Good in Specialized Pharmacies • Access to Care Issues if Limit ADAP Participation • Retrospective Review • Damage Already Done

25. Barriers to Providing Services • Geographic • Urban or Rural Location • Large Client Population • Over 31,000 Unique Clients Served in CY 2007 • Large Pharmacy Network • Over 3,000 Statewide ADAP Participating Pharmacies • Financial • Program • Pharmacy

26. Finally…. • Ideal situation • Thorough pre-treatment counseling • Patient understands goals of therapy • How regimen relates to patient’s daily schedule and meals • Explain side effects, when they may occur and treatments for side effects • Pill boxes, pagers, timers, or medication maps

27. Finally…cont’d • On-going follow-up • Check in session 2 weeks after initiating therapy for new patients • Pill counts • Side effect management • Monitoring for lapses in adherence for “seasoned” patients • Pill or treatment fatigue

28. Finally…. (really) • In the Meantime • Educate providers (pharmacy and prescribers) • PPIs and Atazanavir • Efavirenz and women of child bearing age • Synchronize prescription fills • Use available data to improve care • Clients with low CD4 counts on PCP prophylaxis • Review for duplicate therapy • Review for appropriate prescribing practices

29. Questions