Vanderbilt Specialty Pharmacy Services, Vanderbilt University Medical Center, Nashville, TN.
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
J Manag Care Spec Pharm. 2021 Feb;27(2):256-262. doi: 10.18553/jmcp.2021.27.2.256.
Dalfampridine improves walking speed in patients with multiple sclerosis (MS), but accessing specialty medications such as dalfampridine can be hindered by insurance restrictions, high costs, and limited distribution networks (LDNs) imposed by manufacturers. Some integrated health-systems specialty pharmacies (HSSPs) embed pharmacists in clinics and dispense medications from their internal pharmacies if included within the LDN. To assess access to dalfampridine in patients at an HSSP before and after gaining admission to the LDN. This study was conducted at Vanderbilt Specialty Pharmacy (VSP), an integrated HSSP at Vanderbilt University Medical Center (VUMC) with 2 clinical pharmacists embedded in the MS clinic. VSP gained access to the dalfampridine LDN on May 1, 2018, at which time the embedded pharmacists began to manage the comprehensive therapy initiation process. We performed a retrospective review of adult patients with MS who were prescribed dalfampridine from March 2010 to December 2018. Eligible prescriptions were new starts (no previous use) or restarts (after previous use and discontinuation). Prescriptions were classified as pre-VSP and post-VSP, which differentiates before and after VSP gained access to dispense dalfampridine. Study outcomes were insurance approval, initiation of therapy, and time from treatment decision to medication access. We used a proportional odds logistic regression model for time to medication access using the following covariates: pre-VSP versus post-VSP time period, insurance prior authorization (PA) denied versus approved/not needed, and baseline timed 25-foot walk. We included 262 patients and 290 prescriptions (260 pre-VSP and 30 post-VSP). In pre-VSP and post-VSP prescriptions, 97% were approved by insurance, and 93% of patients started therapy. Median time to medication access was 22 days (IQR = 11-45) for pre-VSP prescriptions and 1 day (IQR = 0-3) for post-VSP prescriptions. In the proportional odds logistic regression model, the odds of having a longer medication access time were significantly higher for pre-VSP prescriptions (OR = 83.219, < 0.001) and prescriptions whose PA was initially denied (OR = 9.50, < 0.001); 25-foot walk time was not significant (OR = 0.95, = 0.277). After obtaining access to dispense dalfampridine, the time to access therapy was reduced, suggesting that LDNs delay patient access to therapy at HSSPs. No funding was provided for this study. The authors have no conflicting interests to disclose. Preliminary results have been previously presented at the American Society of Health-Systems Pharmacy Midyear Meeting in December 2019, the Vanderbilt Health Systems Specialty Pharmacy Outcomes Research Summit in August 2020, and the National Association of Specialty Pharmacy Annual Meeting in September 2020.
地夫可特可改善多发性硬化症（MS）患者的步行速度，但由于保险限制、高成本和制造商设定的有限分销网络（LDN），获得地夫可特等专业药物可能会受到阻碍。一些综合性医疗系统专业药房（HSSP）将药剂师嵌入诊所，如果药物在 LDN 范围内，则从内部药房配药。为了评估在获得 LDN 准入前后 HSSP 中患者获得地夫可特的情况。这项研究是在范德比尔特专业药房（VSP）进行的，VSP 是范德比尔特大学医学中心（VUMC）的一个综合性 HSSP，有 2 名临床药剂师嵌入 MS 诊所。VSP 于 2018 年 5 月 1 日获得地夫可特 LDN 准入，此时嵌入的药剂师开始管理综合治疗启动流程。我们对 2010 年 3 月至 2018 年 12 月期间开用地夫可特的成年 MS 患者进行了回顾性审查。合格的处方是新开始（无先前使用）或重新开始（先前使用和停药后）。处方分为 VSP 前和 VSP 后，这区分了 VSP 获得配药之前和之后的时间。研究结果是保险批准、开始治疗以及从治疗决策到药物获得的时间。我们使用比例优势逻辑回归模型，根据以下协变量计算药物获得时间：VSP 前与 VSP 后时间段、保险预授权（PA）拒绝与批准/无需、基线 25 英尺步行。我们纳入了 262 名患者和 290 张处方（260 张 VSP 前和 30 张 VSP 后）。在 VSP 前和 VSP 后处方中，97%的处方得到了保险的批准，93%的患者开始了治疗。VSP 前处方的药物获得时间中位数为 22 天（IQR=11-45），VSP 后处方的药物获得时间中位数为 1 天（IQR=0-3）。在比例优势逻辑回归模型中，VSP 前处方（OR=83.219，<0.001）和初始 PA 拒绝的处方（OR=9.50，<0.001）获得更长药物获得时间的可能性显著更高；25 英尺步行时间无显著差异（OR=0.95，=0.277）。获得配药后，获得治疗的时间缩短，这表明 LDN 会延迟 HSSP 中患者获得治疗的时间。这项研究没有获得资金支持。作者没有利益冲突需要披露。初步结果之前已在 2019 年 12 月的美国卫生系统药剂师协会中期会议、2020 年 8 月的范德比尔特卫生系统专业药房成果研究峰会以及 2020 年 9 月的全国专业药房协会年会上进行了介绍。
