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Background: Tuberculosis (TB) poses a significant public health challenge in Guinea, with an estimated 22 000 TB cases in 2020; an estimated 6125 (28%) cases went undetected. We evaluated an intensified TB case finding strategy in Guinea which targeted customers who bought cough suppressants from pharmacies or drug outlets., Methods: We involved 25 pharmacies and 25 drug outlets in Matoto, Conakry, Guinea. Pharmacists or outlet owners identified and referred all customers with TB symptoms who were purchasing cough suppressants to healthcare workers for sputum collection either at the pharmacy or drug outlet or at a nearby TB diagnosis and treatment centre (CDT); sputum was subjected to bacteriological testing with acid fast bacilli smear or Xpert MTB/RIF. We assessed factors associated with eventual TB diagnosis using logistic regression and time to TB diagnosis using cox regression and used microcosting to estimate the cost of the intervention in 2020 US$., Results: From November 2019 to June 2020, we screened 916 people referred from pharmacies or drug outlets with TB symptoms, with median age of 31 years (54% male). Overall, 126 (14%) had bacteriologically confirmed TB. Odds of TB diagnosis were significantly lower with increasing age (adjusted OR (aOR) per additional year=0.98; 95% CI 0.97 to 0.99) and higher among males (aOR=1.57; 95% CI 1.04 to 2.39) and those with symptoms. Those identified at drug outlets had significantly faster time to presentation from symptom onset than pharmacies (adjusted HR=1.73; 95% CI 1.50 to 1.99). The total cost of the intervention per person referred was US$32.66 and per person diagnosed and treated for TB disease of US$237.45., Conclusion: Intensified TB case finding through pharmacies and drug outlets is a feasible and effective way to increase TB detection in settings where self-medicating is common, and TB is under-detected., Competing Interests: Competing interests: None declared., (© World Health Organization 2024. Licensee BMJ.)

Importance: In the US, many patients struggle to afford prescription drugs, leading to adverse health outcomes. To improve cost-related medication nonadherence, prescribers and clinical staff must understand how to assist patients in overcoming high prescription drug costs., Observations: We reviewed the benefits and limitations of 7 strategies to help patients afford prescription drugs: co-payment cards, patient assistance programs, pharmacy coupons, direct-to-consumer pharmacies, public assistance programs, international online pharmacies, and real-time prescription benefit tools. We created an algorithm to help clinicians identify appropriate strategies based on a patient's health insurance and the type of drug (brand-name vs generic). For example, co-payment cards can lower out-of-pocket costs for privately insured patients taking brand-name prescription drugs. For uninsured individuals or those with public insurance like Medicare Part D who meet financial eligibility criteria, patient assistance or public assistance programs may be available. All patients, regardless of health insurance, can forgo insurance and purchase drugs directly using pharmacy coupons or direct-to-consumer pharmacies, which sometimes offer lower prices for generic drugs compared to insurance. For insured patients, such purchases do not count toward insurance deductibles or annual out-of-pocket maximums. Online international pharmacies provide a last resort for patients in need of brand-name drugs who lack affordable domestic options. Increasingly, prescribers can use real-time prescription drug benefit tools to estimate patient out-of-pocket costs and identify alternative lower-cost treatments for insured patients, but these tools can be inaccurate or incomplete., Conclusions and Relevance: The current patchwork of strategies to help patients manage high prescription drug costs highlights the structural and policy challenges within the US prescription drug market that impede affordable access for some patients. While these strategies provide tangible solutions for clinicians to help patients access medically appropriate but costly medications, they do not address the root causes of high drug prices.

Background: The aim of this study is to assess the cost savings from medication reviews conducted for individuals living in nursing homes in Estonia. Medication reviews performed as part of the automated dose dispensing (ADD) service by community pharmacies might help identify suboptimal medicine regimens., Methods: We use a case study approach to identify suboptimal use of medication in treatment plans and estimate the potential cost saving from medication reviews. To achieve this, we assess 101 treatment plans submitted for medication review by nursing homes in Estonia between 2021 and 2023. Additionally, we run OLS regressions to identify the most important determinants of medication cost savings., Results: We estimate an average direct cost saving of €43.62 per patient per year, which corresponds to 8.27% of the average annual medication costs. If medication reviews were conducted for all elderly individuals over 75 years old who use six or more prescription medicines, nearly 2% of Estonia's pharmaceutical budget could be saved. Regression analysis indicates that the most significant contributors to these cost savings are suboptimal use of generics, incorrect dosages (too high), and the elimination of incorrect medications., Conclusions: Our study suggests that annual medication reviews conducted as part of the ADD service might help reduce medication expenditure when offered to a wider public., (© 2024. The Author(s).)

Background: Access to cardiovascular medications is severely hampered by their unavailability and high cost, particularly for the poorest households in developing nations. The availability and price range of cardiovascular medications are significantly limited in both hospital and community pharmacies. Objectives: The aim of this study is to assess the availability and price variations of commonly used cardiovascular medicines in hospital pharmacies in Gondar Town, northwest Ethiopia. Methods: From July 13 to August 6, 2022, a mixed cross-sectional and simulated client survey was carried out at two hospital and 13 community pharmacies in Gondar Town. The analysis and data entry were performed using SPSS Version 25 and EpiData Version 4.2, respectively. The availability and pricing variations of the medications are given as percentages. The significance was examined using paired t tests. Results: On average, community retail pharmacies offered 33.22% of CVD drugs. Aspirin (81 mg), amlodipine (5 mg), atorvastatin (20 mg), and hydrochlorothiazide (25 mg) were the most readily available drugs in community pharmacies. Overall, 28.00% of the hospital pharmacies had available CVD medicines during the course of our analysis. The average cost for the 25 CVD medications in hospital pharmacies was $0.699, with a standard deviation (SD) of 1.513, which was less than the cost at community pharmacies ($2.741 with an SD of 6.015) ( p = 0.045). Conclusion: CVD medications were more available in community pharmacies than in hospital pharmacies, although there were fewer CVD medications available than recommended by the WHO/HAI (80%) in both hospital and community pharmacies. There was a statistically significant difference between the two prices. Compared to that at hospital pharmacies, the mean price at community pharmacies was greater., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Liknaw Workie Limenh et al.)

Background: Direct-to-consumer (DTC) pharmacies sell generic prescription drugs, often at lower prices than traditional retail pharmacies; however, not all drugs are available, and prices vary., Objective: To determine the availability and cost of generic drugs at DTC pharmacies., Design: Cross-sectional study., Setting: Five national DTC pharmacies in April and May 2023., Participants: Each qualifying form of 100 generic drugs with the highest cost-per-patient (expensive) and the 50 generic drugs with the highest number of patients (common) in Medicare Part D in 2020 MAIN MEASURES: Availability of these drugs and the lowest DTC pharmacy price for a standardized drug strength and supply (e.g., 30 pills), compared to GoodRx retail pharmacy prices., Key Results: Of the 118 expensive generic dosage forms, 94 (80%) were available at 1 or more DTC pharmacies; out of 52 common generic dosage forms, 51 (98%) were available (p < 0.001). Of the 88 expensive generics available in comparable quantities and strengths across pharmacies, 42 (47%) had the lowest cost at Amazon, 23 (26%) at Mark Cuban Cost Plus Drug Company, 13 (14%) at Health Warehouse, and 12 (13%) at Costco; for 51 common generic formulations, 16 (31%) had the lowest cost at Costco, 14 (27%) at Amazon, 10 (20%) at Walmart, 6 (12%) at Health Warehouse, and 5 (10%) at Mark Cuban Cost Plus Drug Company. For the 77 expensive generics with available GoodRx retail pharmacy prices, the median cost savings at DTC pharmacies were $231 (95% CI, $129-$792) or 76% (IQR, 53-91%); for 51 common generics, savings were $19 (95% CI, $10-$34) or 75% (IQR, 67-83%)., Conclusions: Many of the most expensive generic drugs are unavailable at direct-to-consumer pharmacies. Meanwhile, less expensive, commonly used generics are widely available, but drug prices vary by pharmacy and savings are modest, requiring patients to shop around for the lowest cost., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: In Germany, over-the-counter (OTC) medicines may only be dispensed by community pharmacies (CPs). German CPs must ensure 'adequate' counselling, including the cost of medicines. Along with information gathering and advice giving as classic aspects of counselling, the aim was also to investigate counselling indicators of product and price transparency., Methods: The cross-sectional study was based on the covert simulated patient (SP) methodology and was conducted in a random sample of CPs stratified by districts in the major German city of Munich. Each of the 178 selected CPs was visited once by one of five trained female students. They simulated a symptom-based sub-scenario 1 with a request for an OTC medicine for a headache and a sub-scenario 2 with standardised information regarding product and price transparency. The assessment, completed immediately postvisit by the SPs, included a total of 23 items., Results: All 178 scheduled visits were completed successfully. The median counselling score with the classic items was 3.0 out of 12 points (interquartile range [IQR] 4.25) and when expanded by items for product and price transparency the score was 4.0 out of 14 points (IQR 4.00). A selection of medicines was offered unsolicited in 38.2% of the visits and in 5.6% of the visits voluntary price information was provided before the transaction. A request for a cheaper medicine led to a significant price reduction (Wilcoxon signed-rank test; p < 0.001, r = 0.869)., Conclusion: Due to the below-average level of counselling, the regional chambers of pharmacists are recommended to initiate measures for improvement. There is also potential for optimisation with regard to product and price transparency as an important extension of the classic counselling aspects. It is therefore recommended that the government raise customers' awareness of the cost of medicines., (© 2024 The Author(s). The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: High-priced drugs pose a challenge for health budgets, policies, and patient safety. One of the key roles of community pharmacies is to ensure availability to prescription drugs regardless of their price. This has been identified as challenging in certain situations concerning high-priced drugs., Objectives: The aim is to investigate the views of proprietary pharmacists regarding the effects of high-priced drugs on the day-to-day operations of pharmacies., Methods: The data collection of the study was performed as a national cross-sectional online survey. The inclusion criteria were being a proprietary pharmacist and a member of the Association of Finnish Pharmacies. The survey contained questions yielding both quantitative and qualitative answers. The study focused on the qualitative data which was analysed by deductive thematic analysis., Results: In total 604 proprietary pharmacists were sent the survey, and 174 eligible answers were included in the study, giving a response rate of 29%. The result describes the relationships between the economic, social, and environmental dimensions of sustainable development based on a framework by Wanamaker, with respect to high-priced drugs and community pharmacy operations as viewed by proprietary pharmacists. The main findings of the study show that proprietary pharmacists find the implementation of real-time reimbursement payments, a further reform of the pharmacy tax, and the abolishment of return bans to the wholesaler as risk mitigations and means to attain sustainability with respect to high-priced drugs and pharmacy practice. They experience that these changes would diminish high-priced drugs unnecessarily ending up as medical waste and improve the working conditions of the pharmacy staff by alleviating stress., Conclusions: According to the respondents, high-priced drugs pose challenges for community pharmacies and the legislation and reimbursement system need to adapt to these challenges. If not, community pharmacies in Finland continue to face severe financial declines based on the study results., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Importance: The US Food and Drug Administration approved Narcan, a nasal spray formulation of naloxone, for sale as an over-the-counter (OTC) medication in March 2023. The purpose of OTC approval was to improve naloxone accessibility to reduce opioid overdoses; however, research has not yet evaluated whether naloxone's availability and cost changed since this policy was implemented., Objective: To evaluate whether the accessibility and cost of naloxone at North Carolina community pharmacies changed after OTC naloxone became available and whether cost and availability varied by pharmacy type and urbanicity., Design, Setting, and Participants: This longitudinal telephone-based secret shopper survey study included a stratified sample of 202 North Carolina community pharmacies, including health department, independent, and chain pharmacies. There were 2 separate data collection efforts from March to April 2023 (before OTC naloxone could be sold at pharmacies) and November 2023 to January 2024 (after OTC naloxone was sold at pharmacies)., Exposure: OTC naloxone first became available for sale at community pharmacies in September 2023., Main Outcomes and Measures: The main outcomes were same-day availability of naloxone without a clinician-issued prescription and the quoted out-of-pocket cost for cash-paying patients., Results: Data were collected from 192 pharmacies. Same-day naloxone availability increased from 42.2% (81 of 192) before OTC naloxone availability to 57.8% (111 of 192) after (P < .001). The mean (SD) quoted out-of-pocket cost decreased from $90.93 ($42.6) pre-OTC availability to $62.67 ($41.0) post-OTC availability (P < .001). Independent pharmacies had higher mean (SD) costs than chain pharmacies in both the pre-OTC phase ($109.47 [$37.90] vs $86.40 [$35.70]; P < .001) and post-OTC phase ($77.59 [$38.90] vs $57.74 [$35.90]; P = .004). Out-of-pocket costs did not differ by urbanicity in the pre-OTC phase; however, mean (SD) costs were higher at suburban ($88.67 [$66.80]) and rural ($65.43 [$35.00]) pharmacies compared with urban pharmacies ($53.58 [$29.00]) in the post-OTC phase (P = .003)., Conclusions and Relevance: The Food and Drug Administration's approval of OTC naloxone nasal spray contributed to an increase in pharmacy-based availability of naloxone and a reduction of its cost for cash-paying patients. Cost was higher at independent pharmacies compared with chain pharmacies and lower in urban pharmacies compared with suburban and rural pharmacies.

Introduction: Integrated delivery networks can use medically integrated dispensing of oral oncolytics on site through health system specialty pharmacies. There is little published research examining cost savings. Our objective was to demonstrate the financial value of health system specialty pharmacies among patients receiving oral oncolytics dispensed through fully, partially, and non-integrated dispensing strategies., Methods: This was a retrospective cohort study of adult patients from Symphony Health's Integrated Dataverse ® repository who filled a prescription for an agent of interest from 7/1/16-6/30/20 that was written within 25 US health systems. Outcomes included costs, healthcare resource utilization, and duration of therapy., Results: In total, 36,816 patients were included; 986 patients (2.7%) integrated, 1,822 (4.9%) partially integrated, and 34,008 (92.4%) non-integrated. Mean 6-month medical charge and oncolytic prescription costs were lower for the integrated group ($36,831; $55,786) than the partially integrated ($46,304, p  = 0.053; $63,295, p  = 0.071) and non-integrated groups ($54,261, p  < 0.001; $65,005, p  = 0.004). In most healthcare resource utilization categories, the integrated group had the lowest patient percentage utilizing medical care. Duration of therapy was lower on average by ∼3 months in the integrated vs non-integrated group, which may represent closer monitoring of patient medical records and need for fills vs autoship practices., Conclusions: Patients receiving oral oncolytics through medically integrated dispensing at health system specialty pharmacies may have lower medical and pharmacy costs and decreased healthcare resource utilization. This study adds to the growing body of literature supporting integrated delivery networks and integrated dispensing. Further research is needed to demonstrate the value of medically integrated dispensing through health system specialty pharmacies in the delivery of treatment to patients with cancer and other high-cost diseases., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Affordability of medicines is key for effective healthcare. Thus, we compared medicine prices using International Dollar (I$), which allows confronting the values of different currencies. Besides, we intended to verify if pharmaceutical market deregulation leads to lower medicines prices., Materials and Methods: We conducted the study between December 2019 and September 2022 collecting data from 21 countries. From the preliminary sampling of 30 medicines, we selected 10 brand names (5 Rx and 5 OTC brands) for the analysis. In each country, we collected price information from 3 pharmacies and then converted them to the I$ using the rates published by the International Monetary Fund., Results: There were differences between regulated and deregulated markets in prices presented in I$. For instance, Aspirin C® (10 soluble pills) was on average I$ 5.41 in Finland (regulated market) and I$ 13.25 in Brazil. The most expensive Xarelto® 20 x 28 pills (I$ 538.40) was in Romania, which in the case of other medicines, was in the group of cheaper countries. There was no statistical significance in price comparison between regulated and deregulated markets. In some cases, however, regulated markets offered lower prices of the same medicine than deregulated markets., Conclusion: The analysis revealed differences in I$ prices between countries. Pharmaceutical market regulation does not mean higher prices of medicines. There is a need for affordable medicines. Hence, decision-makers should work on the medicines prices and adjust them to the local economies. I$ could be important in creating pharmaceuticals prices, and the conducted study should encourage other researchers to present their results using this currency., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Zaprutko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The dispensation of medicines in some low- and middle-income countries is often carried out by private vendors operating under constrained conditions. The aim of this study was to understand the challenges reported by employees of dispensaries, specifically, chemical and herbal shops and pharmacies in Accra, Ghana. Our objectives were twofold: (1) to assess challenges faced by medicine vendors related to dispensing antimicrobials (antibiotic and antimalarial medications), and (2) to identify opportunities for improving their stewardship of antimicrobials., Methods: Data were collected in 79 dispensaries throughout Accra, in 2021, using a survey questionnaire. We used open-ended questions, grounded on an adapted socioecological model of public health, to analyze these data and determine challenges faced by respondents., Results: We identified multiple, interlocking challenges faced by medicine vendors. Many of these relate to challenges of antimicrobial stewardship (following evidence-based practices when dispensing medicines). Overall, medicine vendors frequently reported challenges at the Customer and Community levels. These included strained interactions with customers and the prohibitive costs of medications. The consequences of these challenges reverberated and manifested through all levels of the socioecological model of public health (Entity, Customer, Community, Global)., Discussion: The safe and effective distribution of medications was truncated by strained interactions, often related to the cost of medicines and gaps in knowledge. While addressing these challenges requires multifaceted approaches, we identified several areas that, if intervened upon, could unlock the great potential of antimicrobal stewardship. The effective and efficient implementation of key interventions could facilitate efforts spearheaded by medicine vendors and leverage the benefits of their role as health educators and service providers., Conclusion: Addressing barriers faced by medicine vendors would provide an opportunity to significantly improve the provision of medications, and ultimately population health. Such efforts will likely expand access to populations who may otherwise be unable to access medications and treatment in formal institutions of care such as hospitals. Our findings also highlight the broad range of care provided by shopkeepers and vendors at dispensaries. These findings suggest that the meaningful engagement of dispensaries as valued conduits of community health is a promising pathway for interventions aiming to improve antimicrobial stewardship., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Greene et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription., Objective: The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC., Methods: A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality., Results: Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ 2  = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F 2 , 136  = 2.38, P = 0.10)., Conclusion: Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product., Competing Interests: Disclosure Nabarun Dasgupta is an uncompensated Board member of the nonprofit organization Remedy Alliance For The People, which distributes bulk naloxone to public health programs and health departments. Bayla Ostrach is an uncompensated Board of the nonprofit organization for Musicians for Overdose Prevention, which distributes free naloxone to musicians, bands, music venues, and other music-related settings. The authors declare no other relevant conflicts of interest or financial relationships., (Copyright © 2024. Published by Elsevier Inc.)

This study explored and compared the associations between pharmacy competition and drug expenditures by individuals with influenza. This study used a dataset consisting of 6 694 534 individuals who purchased drugs for influenza at pharmacies from 2015 to 2019 in China. Patients' annual average influenza-specific drug expenditures per visit at pharmacies was the outcome variable of interest. Pharmacy competition was measured using the Herfindahl-Hirschman index. A 3-way fixed-effects model combined with a lagged identification strategy was constructed to estimate the association between pharmacy competition and drug expenditures. When the radius of the market was set to 1, 5, and 10 km, for each 10% increase in the degree of total competition in the market, an individual's annual average influenza-specific drug expenditures per visit fell by 0.65%, 2.21%, and 5.20%, respectively. With a more detailed understanding of the underlying mechanism through which pharmacy competition affects the behaviors of health care providers, competition can be considered as a potential tool to assist decision makers in the design of policies to curtail the growth in drug expenditures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The essential medicine--insulin cannot be easily accessed and afforded in many countries. To help address this issue, we evaluated the availability, affordability and price of insulin products in Nanjing, eastern China. Two cross-sectional studies were conducted in 2016 and 2018. A total of 56 hospital pharmacies were sampled, using a simplified and adapted World Health Organization/Health Action International (WHO/HAI) methodology. Prices were expressed as Median Price Ratios (MPRs) to Australian Pharmaceutical Benefit Scheme (PBS) prices. In addition, we investigated the price components of seven selected insulin products as a case study before and after the Online Centralized Procurement Policy for Hospital Drugs in May, 2018. Affordability was presented as the number of daily wages of the lowest paid unskilled government worker (LPGW) required to purchase 1000IU of insulin based on the average courses of treatment, approximately 30 days' treatment. The availability of insulin products was very high in secondary hospitals and tertiary hospitals both in 2016 and 2018, but in community hospitals was very low. In 2018, the availability of prandial insulin products showed fluctuation compared to 2016. The availability of pre-mixed human insulin products was over 95% overall, and also very high (80%) in community hospitals in 2018. The prices of insulin products were much lower than PBS prices of Australian in this study, with the MPRs less than 1 (0.32 to 0.71 in 2016 vs. 0.30 to 0.68 in 2018) for all insulin types. But insulin products in Nanjing in 2016 and 2018 were considered unaffordable, because the number of daily wages of the LPGW needed to purchase for the 30 days treatment of insulin products ranged from 2.26 to 8.49 in 2016 and 1.88 to 7.09 in 2018. The manufacturers' selling price contributed the main part (74.15% to 77.70% before and 74.86% to 91.51% after the implementation of the bidding policy) of the price components of target insulin brands. The availability of insulin products was high in secondary hospitals and tertiary hospitals, but lower in community hospitals. However, the affordability in community hospitals was better than other hospitals, but the insulin products were still unaffordable for patients on low incomes. Further improvements of the availability accessibility and affordability of medicines in advancing health insurance policies and lowering drug prices should be put forward., Competing Interests: The authors have declared that no competing interests exist.

Background: Lockdowns and shelter-in-place orders during COVID-19 have accelerated the adoption of remote and virtual care (RVC) models, potentially including telehealth, telemedicine, and internet-based electronic physician visits (e-visits) for remote consultation, diagnosis, and care, deterring small health care businesses including clinics, physician offices, and pharmacies from aligning resources and operations to new RVC realities. Current perceptions of small health care businesses toward remote care, particularly perceptions of whether RVC adoption will synergistically improve business sustainability, would highlight the pros and cons of rapidly adopting RVC technology among policy makers., Objective: This study aimed to assess the perceptions of small health care businesses regarding the impact of RVC on their business sustainability during COVID-19, gauge their perceptions of their current levels of adoption of and satisfaction with RVC models and analyze how well that aligns with their perceptions of the current business scenario (SCBS), and determine whether these perceptions influence their view of their midterm sustainability (SUST)., Methods: We randomly sampled small clinics, physician offices, and pharmacies across Colorado and sought assistance from a consulting firm to collect survey data in July 2020. Focal estimated study effects were compared across the three groups of small businesses to draw several insights., Results: In total, 270 respondents, including 82 clinics, 99 small physician offices, and 89 pharmacies, across Colorado were included. SRVC and SCBS had direct, significant, and positive effects on SUST. However, we investigated the effect of the interaction between SRVC and SCBS to determine whether RVC adoption aligns with their perceptions of the current business scenario and whether this interaction impacts their perception of business sustainability. Effects differed among the three groups. The interaction term SRVC×SCBS was significant and positive for clinics (P=.02), significant and negative for physician offices (P=.05), and not significant for pharmacies (P=.76). These variations indicate that while clinics positively perceived RVC alignment with the current business scenario, the opposite held true for small physician offices., Conclusions: As COVID-19 continues to spread worldwide and RVC adoption progresses rapidly, it is critical to understand the impact of RVC on small health care businesses and their perceptions of long-term survival. Small physician practices cannot harness RVC developments and, in contrast with clinics, consider it incompatible with business survival during and after COVID-19. If small health care firms cannot compete with RVC (or synergistically integrate RVC platforms into their current business practices) and eventually become nonoperational, the resulting damage to traditional health care services may be severe, particularly for critical care delivery and other important services that RVC cannot effectively replace. Our results have implications for public policy decisions such as incentive-aligned models, policy-initiated incentives, and payer-based strategies for improved alignment between RVC and existing models., (©Madhavan Parthasarathy, Jiban Khuntia, Rulon Stacey. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 25.02.2021.)

Background: Research on socio-ecological factors that may impede or facilitate access to naloxone in pharmacies remains limited. This study investigated associations between socio-ecological factors, pharmacy participation in the naloxone cost assistance program (NCAP), pharmacy characteristics and having naloxone in stock among pharmacies in New York City., Methods: Phone interviews were conducted with 662 pharmacies selected from the New York City Naloxone Standing Order List. Multi-level generalized linear modeling estimated associations between neighborhood racial and ethnic composition, poverty rates, overdose fatality rates, pharmacy participation in N-CAP, having private physical spaces within the pharmacy, knowledge of where to refer people to obtain naloxone and adjusted relative risk (aRR) that the pharmacy would have naloxone in stock., Results: Findings from this study supported several of the hypotheses. Greater neighborhood poverty was associated with a lower likelihood of carrying naloxone compared to neighborhoods with less poverty (aRR = .79, CI95 % = .69, .90, p < .001). Pharmacies that provided a private window for consultations (aRR = 1.34, CI95 % = 1.19, 1.51, p < .001), a private room (aRR = 1.42, CI95 % = 1.30, 1.56, p < .001), and a private area (aRR = 1.42, CI95 % = 1.30, 1.56, p < .001) were associated with a higher likelihood of carrying naloxone compared than those that did not., Conclusions: Findings from this study suggest that community-level socioeconomic marginalization is a contributor to disparities in naloxone availability among pharmacies in New York City. Findings support harm reduction interventions tailored to the built environment of pharmacies that respect privacy to those seeking naloxone., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To measure the situation of the non-prescription sale of antibiotics and the service quality of community pharmacies in Guangzhou, China., Methods: A simulated client method was conducted to estimate the non-prescription sale of antibiotics and service quality based on scenarios about adult acute upper respiratory tract infection in 2019. A total of 595 community pharmacies from 11 districts were investigated in Guangzhou, China. We used binary logistic regression to evaluate the factors associated with the non-prescription sale of antibiotics., Results: The proportion of non-prescription dispensing of antibiotics was 63.1% in Guangzhou, China, with a higher incidence of antibiotic dispensing without prescription in outer districts (69.3%). Cephalosporin (44.1%) and Amoxicillin (39.0%) were sold more often than other antibiotics. Chain pharmacies had better performance on the prescription sale of antibiotics and service quality. Traditional Chinese medicine was commonly recommended by pharmacy staff., Conclusion: Since the non-prescription sale of antibiotics is prevalent in Guangzhou, effective solutions should be determined. Strengthened public awareness and regulatory system innovation are needed., Competing Interests: The authors have declared that no competing interests exist.

Background: Very little is known about the effects of drug wastage costs among cancer patients in terms of "financial toxicity" leading to poor health and nonhealth outcomes. But reducing this drug waste is an attractive strategy for cost-cutting with regard to improving the health-related quality of life of the cancer patients. Thus, the objective of the study was to determine drug wastage and to generate evidence for cytotoxic drug waste and financial burden among cancer patients. Methodology: On Ethics Committee approval, a prospective-observational study was conducted in cancer patients. The data were collected in data collection form. Daily monitoring was done to analyze the quantity of drug wastage which was interpreted using KW-ANOVA and further evidence was developed for corrective mitigation strategies applicable to intent drugs., Results: Among 90 patients, 52 patients experienced drug wastage that includes 9 intent drugs which figured out unnecessary monetary units and quantity wastage that range from 80 to 50,000 INR and 10 to 500 mg, respectively. The median price value for cost of drug wastage was 237.30 INR., Conclusion: The study generates evidence that concludes the mandatory requirement of implementation of drug wastage mitigation strategies for the drugs expected to cause wastage. Clinical pharmacist extensively contributes in oncology pharmacy practice setting to identify the intent drugs and to abate the drug wastage among medications intending to cause potential increment in drug expenditure among cancer patients on chemotherapy clinical pharmacist.

Recently, both the Canadian and provincial governments have instituted policies to reduce manufacturers' prices for generic ($250 million sales annually) and brand name ($1,300 million sales annually) drugs. Both government groups made estimates of the financial magnitude of changes in drug prices, but neither has estimated the impact on retail pharmacies. We used a Cost-Volume-Profit model combined with operational data collected nationally to estimate the national impact of the pricing policy changes on pharmacy gross profits. Results show the average value of gross profits per pharmacy per year was approximately $440,000. It is estimated that the policy changes will lead to a 6.8% reduction in gross profits. Adding reductions in rebates for generic drugs, the pharmacies' reductions in gross profits will be 7.2%. In conclusion, policy-makers often ignore how their pricing changes influence the financial position of pharmacies, even though the impact can be substantial.

Introduction: Even though evidence-based diabetes prevention interventions exist, more than 1 in 3 Americans have prediabetes; the use of pharmacies has been explored as a way to reach and care for this population. The objective of this study was to analyze factors that influence adoption of type 2 diabetes prevention programs by community pharmacies., Methods: We conducted 21 semistructured interviews in 2018 with decision makers from 11 independent pharmacies in 6 US states and the District of Columbia and from 10 chain pharmacies operating in 1 state, multiple states, and nationwide. We identified participants by using purposive sampling. We used qualitative methods to analyze data and conducted interviews until we reached saturation., Results: Multiple themes emerged: 1) initiation of services is more likely if initial financial support is received; 2) patient demand for services, actual or perceived, is paramount; 3) diabetes prevention services often fit within the existing operations of a pharmacy and allow maximum use of resources; 4) customer loyalty is a clearly articulated advantage against competition; and 5) engagement in diabetes prevention affirms an expanded role and the value of pharmacies to serve communities., Conclusion: Pharmacies are well situated to deliver diabetes prevention programs to communities. Although considerable opportunity exists for pharmacies to address diabetes prevention, more could be done to reduce barriers to their use.

Background: Policymakers have recognized that proprietary patent medicine vendors (PPMVs) can provide an opportunity for effective scaling up of artemisinin-based combination therapy (ACT) since they constitute a major source of malaria treatment in Nigeria. This study was designed to determine the stocking pattern for anti-malarial medications, knowledge of the recommended anti-malarial medicine among PPMVs in Akinyele Local Government Area (LGA) of Oyo State, Nigeria and their perception on ways to improve PPMV adherence to stocking ACT medicines., Methods: A cross-sectional survey was conducted among 320 PPMVs using a mixed method of data collection. Survey respondents were consecutively selected as a complete listing of all the PPMVs was not available. A pretested interviewer-administered questionnaire was used to collect quantitative data and two focus group discussions (FGD) were conducted among PPMVs using a pretested FGD guide., Results: Most PPMVs stocked artemether-lumefantrine (90.9%), dihydroartemisinin-piperaquine (5.3%) and artesunate-amodiaquine (2.8%). Drugs contrary to the policy, which included sulfadoxine-pyrimethamine, chloroquine, quinine, halofantrine, artesunate, and artemether were stocked by 93.8, 22.8, 0.6, 1.3, 6.6, and 7.8% of the PPMVs, respectively. Most PPMVs (96.3%) had good knowledge of artemether-lumefantrine as the first-line treatment for malaria and 2.8% had good knowledge of artesunate-amodiaquine as the alternate treatment for malaria. The major factors influencing stocking decision were government recommendations (41.3%) and consumer demand (40.30%)., Conclusion: Stocking of artemisinin-based combinations was high among PPMVs, although they also stocked and dispensed other anti-malarial drugs and this has serious implications for drug resistance development. The PPMVs had considerable knowledge of the recommended treatment for uncomplicated malaria and stocking decisions were overwhelmingly driven by consumer demand. However, there is a need for more enlightenment on discontinuation of government-banned anti-malarial drugs.

Background: Access to affordable and good quality medicines is a key to meeting Sustainable Development Goal No. 3 by the year 2030. Prices, availability and affordability of essential medicines have been studied in many developing countries, but no such information has been published about Rwanda yet. This study aimed at providing data on prices, availability and affordability of medicines in different health facilities of Rwanda., Methods: A survey was carried out on availability, prices and affordability of 18 medicines in Kigali City and five districts of Rwanda. 44 health facilities were surveyed, including public and faith-based hospitals, public and faith-based health centers and private pharmacies. The standardized methodology developed by WHO and Health Action International (HAI) was used to collect and analyze the data., Findings: Prices for generic medicines in public and faith-based health facilities were remarkably low, with median price ratios (MPRs) of 1.0 in comparison to the international procurement prices published by Management Sciences for Health. In private pharmacies, prices were twice as high (MPR = 1.99 for generics). Availability of medicines fell short of the of 80% target set by WHO, but was better than reported from many other developing countries. Availability of medicines was highest in the private sector (71.3%) and slightly lower in the faith-based (62.8%) and public (59.6%) sectors. The government procurement agency was found to work efficiently, achieving prices 30% below the international procurement price given in the International Medical Product Price Guide. Affordability of medicines was better in the public and faith-based sectors than in the private sector., Conclusion: In Rwanda, medicines are affordable but poorly available in both the public and the faith-based sectors. Further improvements of the availability of medicines in the public and the faith-based health facilities represent the most important key to increase accessibility and affordability of medicines in Rwanda., Competing Interests: The authors have declared that no competing interests exist.

Background: Joint procurement of medicines is a way to improve access and justice in developing countries. The aim of this study is to determine local indicators for assessing the performance of joint procurement agencies and compare the indicators in those pharmacies which use centralized purchasing before and after this change., Methods: This was a mixed method study. In the first qualitative phase, 3 expert panels were held including 20 national experts who were selected through purposeful sampling. Data was analyzed applying a five-stage framework analysis using MAXQDA. In the second quantitative phase, financial, supply and procurement, physical and functional indicators of two hospitals affiliated with joint procurement were assessed and the satisfactions of patients from the pharmacy performance were compared applying a valid questionnaire. Data was analyzed using SPSS through independent test, Paired t-test and ANOVA., Results: Results show that after settlement of joint procurement, the cost of transportation has increased by 54%, a part of the cost of overhead has increased by 30%, the cost of manpower has increased by 88.9% and cost of insurance of warehouses has increased by 71.85% in 2016 compared to 2015. In addition, the total costs of holding were 89.8% of selling revenue. In other words, the profit was about 10% of revenue in total. Moreover the average score of pharmacies under the Holding has been higher than similar ones in all aspects of satisfaction from the patients` points of view., Conclusion: The one-year experience of deploying centralized purchasing to supply medicine has led to increased income and patient satisfaction. However, increase in staffing costs, longevity, overhead and warehouse costs have been significant that need appropriate monitoring and interventions. Graphical abstract Graphical abstract of lessons from one year experience of pooled procurement of pharmaceuticals in south of Iran.

Disclosures: No funding was received for the writing of this commentary. Stull is employed by Employers Health, which is an employer-founded and employer-led group-purchasing organization with a focus on managing contracts for self-funded plan sponsors with PBMs. It also hosts educational conferences and events for which it receives sponsorships from a variety of health benefit suppliers, including pharmaceutical manufacturers, insurance carriers, PBMs and others. Gupton has nothing to disclose.

Disclosures: No funding supported the writing of this commentary. The author has nothing to disclose.

Disclosures: No funding supported the writing of this commentary. The author has nothing to disclose.

Disclosures: No funding was received for the writing of this commentary. The author has nothing to disclose.

Objectives: To examine patterns of generic escitalopram initiation and substitution among Medicare beneficiaries., Methods: This retrospective new user cohort used a 5% random sample of 2013-2015 Medicare administrative claims data. Fee-for-service Medicare beneficiaries continuously enrolled in Parts A, B, and D during a 6-month washout period prior to their initial generic or brand oral escitalopram prescriptions were included (n = 12,351). The primary outcomes were generic escitalopram treatment initiation, and among brand escitalopram initiators, generic substitution within 12 months. Patient demographics, health service utilization, and prescription level factors were measured and assessed., Results: Among all escitalopram initiators, about 88.2% Medicare beneficiaries initiated generic escitalopram. Beneficiaries who were younger age, male, residing in non-Northeast regions or urban area, in the Part D plan deductible benefit phase, and filling prescriptions at community/retail pharmacies were more likely to initiate generic treatment. Among brand escitalopram initiators (n = 1,464), about 20.7% switched to generic escitalopram, 31.2% switched to another alternative antidepressant, 25.1% discontinued treatment, and 8.7% were lost to follow up or passed away within 12 months after brand initiation. Factors associated with generic escitalopram substitution included region (Midwest vs. Northeast, adjusted hazard ratio (HR) = 1.46, 95% CI = 1.04-2.05), pre-index hospitalization (HR = 1.31; 95% CI = 1.16-1.48) and lower escitalopram average daily dosage (HR = 0.97; 95% CI = 0.95-0.99)., Conclusions: In 2013-2015, almost 90% Medicare beneficiaries initiated generic escitalopram treatment. Among brand escitalopram initiators, about 1 in 5 patients switched to generic escitalopram within 1 year, as compared to 1 in 4 or 1 in 3 who discontinued current or switched to alternative treatment, respectively. Medicare beneficiary's geographic region was independently associated with generic escitalopram initiation and substitution. Findings from this study not only provide up-to-date evidence in generic escitalopram use patterns among Medicare population, but also can guide educational and practice interventions to further increase generic escitalopram use., Competing Interests: In the past 3 years, RAH has provided expert testimony for Daiichi Sankyo and Takeda. Co-author ZW is employed by the U.S. Food and Drug Administration (FDA), specifically by the Center for Drug Evaluation and Research (CDER). IH and ZK are employed by IMPAQ International LLC. There are no patents, products in development or marketed products to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objective. To quantify the monetary value of economic contributions of a state-funded college of pharmacy as it pursues its missions of teaching, research, service, and patient care. Methods. An economic analysis was performed by applying the Impact Analysis for Planning (IMPLAN) Economic Input-Output Model to financial and enrollment data of the University of Tennessee Health Science Center College of Pharmacy. Results. A total of $94.1 million was attributed to the college in fiscal year 2018, which included $50.7 million of total direct expenditures by the college, its students, and visitors; the indirect effect of over $17 million; and the induced effect of $26.4 million. The college directly employed 117 full-time equivalent employees and 39 pharmacy residents, and supported 763 additional jobs through the economic activities it stimulated. In addition, the presence of the college and its economic contribution enabled federal, state, and local taxing authorities to collect $12 million in tax revenues to support government and public programs. Conclusion. Demonstrating the economic value of colleges of pharmacy is critical when seeking support from campus administrators, state legislators, charitable foundations, government agencies, and industry., (© 2020 American Association of Colleges of Pharmacy.)

Online coupon retailers and pharmacies are popular sites that patients can access discounted medications when compared to cash prices. These sources are especially important for those patients without insurance. In our study, we analyzed commonly prescribed topical and oral medications and compared the cash prices to the discounted medications based on a typical month of usage. We found savings in every one of the medications that we analyzed, some with savings up to hundreds of dollars. Savings were present in all the sources analyzed, with the coupon-based programs often having the lowest price. We suggest certain alternative prescribing guidelines when considering patients who may not be able to afford cash prices of medications. Our hopes with this study are to quantify savings for discounted medications as well as to help physicians target more affordable medications for their patients.

Introduction: Beginning September 3, 2014, CVS Health stopped selling tobacco products in all of its retail stores nationwide. This study assessed the impact of removing tobacco sales from CVS Health on cigarette smoking behaviors among U.S. adult smokers., Methods: CVS Health retail location data (2012-2016) were linked with data from the Behavioral Risk Factor Surveillance System, a phone-based survey of the non-institutionalized civilian population aged ≥18 years. Using a difference-in-differences regression model, quit attempts and daily versus nondaily smoking were compared between smokers living in counties with CVS stores and counties without CVS stores, before and after CVS's removal of tobacco sales. Control variables included individuals' sociodemographic and health-related variables, state tobacco control variables, and urban status of counties. Analyses were conducted in 2018., Results: During the 2-year period following the removal of tobacco sales from CVS Health, smokers living in counties with high CVS density (≥3.5 CVS stores per 100,000 people) had a 2.21% (95% CI=0.08, 4.33) increase in their quit attempt rates compared with smokers living in counties without CVS stores. This effect was greater in urban areas (marginal effect: 3.03%, 95% CI=0.81, 5.25); however, there was no statistically significant impact in rural areas. Additionally, there was no impact on daily versus nondaily smoking in either urban or rural areas., Conclusions: Removing tobacco sales in retail pharmacies could help support cessation among U.S. adults who are attempting to quit smoking, particularly in urban areas., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Aims of the Study: Healthy adults have had the option to receive prescriptionless vaccination against influenza in pharmacies of several Swiss cantons since the 2015/16 influenza season. We aimed to assess in a cost-benefit analysis the resulting net benefits for the Swiss economy and public health, and the benefits that could be expected if an extension of the current vaccination recommendations was implemented., Methods: The proportion of influenza vaccines administered in pharmacies was calculated from data provided by pharmacies entering information in phS-net.ch, data from vaccines covered by insurance companies, and vaccine supply data. The economic and public health impact was estimated in a cost-benefit analysis based on published data., Results: In the 2016/17 and 2017/18 influenza seasons, 7306 of a total of 1.07 million (0.7%) and 15,617 of a total of 1.15 million (1.4%) influenza vaccine doses, respectively, were administered in pharmacies in Switzerland. The net cost savings for the economy due to vaccination in pharmacies in the 2016/17 and 2017/18 seasons were CHF 66,633 and CHF 143,021, respectively. In the 2017/18 season, this resulted –in a net saving per 100,000 inhabitants of CHF 1918, 94.4 cases of illness, 17.6 visits to primary care physicians, 0.328 hospitalisations, 1.1 hospitalisation days, 0.019 deaths prevented, and 0.353 life-years gained. Influenza vaccination proved to be cost-effective provided that a vaccine efficacy of 59% is exceeded. Extrapolations for the healthy, working-age population revealed that a vaccination coverage rate of 50% and a vaccine efficacy of 70% could save the Swiss economy CHF 18.4 million annually., Conclusions: The service allowing citizens to receive influenza vaccination in Swiss pharmacies is sparsely used. Since influenza vaccination is cost-beneficial as soon as vaccine efficacy surpasses a critical threshold, an extension of the vaccine recommendation for healthy, working-age adults should be considered from an economic point of view., (EMH Swiss Medical Publishers Ltd.)

Objectives: To explore availability, prices and affordability of essential medicines for diabetes and hypertension treatment in private pharmacies in three provinces of Zambia., Methods: A cross-sectional survey was conducted in 99 pharmacies across three Zambian provinces. Methods were based on a standardized methodology by the World Health Organization and Health Action International. Availability was analysed as mean availability per pharmacy and individual medicine. Median prices were compared to international reference prices and differences in price between medicine forms (original brand or generic product) were computed. Affordability was assessed as number of days' salaries required to purchase a standard treatment course using the absolute poverty line and mean per capita provincial household income as standard. An analysis identifying medicines considered both available and affordable was conducted., Results: Two antidiabetics and nine antihypertensives had high-level availability (≥80%) in all provinces; availability levels for the remaining surveyed antidiabetics and antihypertensives were largely found below 50%. Availability further varied markedly across medicines and medicine forms. Prices for most medicines were higher than international reference prices and great price variations were found between pharmacies, medicines and medicine forms. Compared to original brand products, purchase of generics was associated with price savings for patients between 21.54% and 96.47%. No medicine was affordable against the absolute poverty line and only between four and eleven using mean per capita provincial incomes. Seven generics in Copperbelt/Lusaka and two in Central province were highly available and affordable., Conclusions: The study showed that the majority of surveyed antidiabetic and antihypertensive medicines was inadequately available (<80%). In addition, most prices were higher than their international reference prices and that treatment with these medicines was largely unaffordable against the set affordability thresholds. Underlying reasons for the findings should be explored as a basis for targeted policy initiatives., Competing Interests: The authors have declared that no competing interests exist.

Performance-based financing (PBF) is being implemented across low- and middle-income countries to improve the availability and quality of health services, including medicines. Although a few studies have examined the effects of PBF on the availability of essential medicines (EMs) in low- and middle-income countries, there is limited knowledge of the mechanisms underlying these effects. Our research aimed to explore how PBF in Cameroon influenced the availability of EMs, and to understand the pathways leading to the experiential dimension related with the observed changes. The design was an exploratory qualitative study. Data were collected through in-depth interviews, using semi-structured questionnaires. Key informants were selected using purposive sampling. The respondents (n = 55) included health services managers, healthcare providers, health authorities, regional drugs store managers and community members. All interviews were recorded, transcribed and analysed using qualitative data analysis software. Thematic analysis was performed. Our findings suggest that the PBF programme improved the perceived availability of EMs in three regions in Cameroon. The change in availability of EMs experienced by stakeholders resulted from several pathways, including the greater autonomy of facilities, the enforced regulation from the district medical team, the greater accountability of the pharmacy attendant and supply system liberalization. However, a sequence of challenges, including delays in PBF payments, limited autonomy, lack of leadership and contextual factors such as remoteness or difficulty in access, was perceived to hinder the capacity to yield optimal changes, resulting in heterogeneity in performance between health facilities. The participants raised concerns regarding the quality control of drugs, the inequalities between facilities and the fragmentation of the drug management system. The study highlights that some specific dimensions of PBF, such as pharmacy autonomy and the liberalization of drugs supply systems, need to be supported by equity interventions, reinforced regulation and measures to ensure the quality of drugs at all levels., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Purpose: Many medications that were marketed prior to 1962 but lack Food and Drug Administration (FDA) approval are prescribed in the United States. Usage patterns of these "unapproved medications" are poorly elucidated, which is concerning due to potential lack of data on safety and efficacy. The purpose of this project was to characterize purchases of unapproved medications within the Veterans Health Administration (VHA) by type, frequency, and cost., Methods: VHA purchasing databases were used to create a list of all products with National Drug Codes (NDCs) purchased nationwide in fiscal year 2016 (FY16). This list was compared to FDA databases to identify unapproved prescription medications. For each identified combination of active pharmaceutical ingredient (API) and route of administration ("API/route combination"), numbers of packages purchased and associated costs were added., Results: VHA pharmacy purchasing records contained 3,299 unapproved products with NDCs in FY16. After excluding equipment, nutrition products, compounding ingredients, nonmedication products, and duplicate NDCs, there were 600 unique NDCs associated with 130 distinct API/route combinations. The most commonly acquired product was prescription sodium fluoride dental paste (350,775 packages). The greatest pharmaceutical expenditure was for sodium hyaluronate injection ($24.5 million). Unapproved products accounted for less than 1% of overall VHA pharmacy purchasing in FY16., Conclusion: VHA purchased many unapproved prescription products in FY16 but is taking action to address use of such products in consideration of safety and efficacy data and available alternatives., (Published by Oxford University Press on behalf of the American Society of Health-System Pharmacists 2019.)

Background: Pharmacy interventions are a subset of public health interventions and its research is usually performed within the scope of a trial. The economic evaluation of pharmacy interventions requires certain considerations which have some similarities to those of public health interventions and to economic evaluations alongside trials. The objective of this research is to perform an overview of systematic reviews of economic evaluations of pharmacy services and triangulate results with recommendations for economic evaluations of both public health interventions and alongside trials., Methods: (1) Exploratory review of recommendations on the economic evaluation of public health interventions, (2) exploratory review of recommendations for conducting economic evaluations alongside trials, (3) overview of systematic reviews of economic evaluations of pharmacy interventions (protocol registered with PROSPERO 2016 outlining information sources, inclusion criteria, appraisal of reviews and synthesis methods)., Results: Fourteen systematic reviews containing 75 index publications were included. Reviews reported favorable economic findings for 71% of studies with full economic evaluations. The types of economic analysis are diverse. Two critical quality domains are absent from most reviews. Key findings include the following: certain types of risk of bias, wider scope of study designs, and most economic quality criteria met but some issues unresolved or unclear. Triangulation revealed additional gaps. Limitations include choice of critical quality domains and potential biases in the overview process., Conclusions: Economic evaluations of pharmacy-based public health interventions seem to follow most economic quality criteria, but there are still some issues in certain key areas to improve. These findings may assist in improving the design of pilot trials of economic evaluations in pharmacy, leading to robust evidence for payers. Based on the findings, we propose a methodological approach for the economic evaluation of pharmacy-based public health interventions., Systematic Review Registration: PROSPERO CRD42016032768.

Background: Cash prices for prescription drugs vary widely in the United States., Objective: To describe cash price variation by retail pharmacy type for 10 generic and 6 brand-name drugs throughout the United States and stratified by ZIP code., Design: Cross-sectional study., Setting: Drug pricing data from GoodRx, an online tool for comparing drug prices, representing more than 60 000 U.S. pharmacies (fall 2015)., Measurements: Cash prices for a 1-month supply of generic and brand-name drugs were ascertained. Stratified by ZIP code, relative cash prices for groups of generic and brand-name drugs were estimated for big box, grocery-based, small chain, and independent pharmacies compared with a reference group of large chain pharmacies., Results: Across 16 325 ZIP codes, 68 353 unique pharmacy stores contributed cash prices. When stratified by 5-digit ZIP code, the relative cash prices for generic drugs at big box, grocery-based, small chain, and independent pharmacies compared with those at large chain pharmacies were 0.52 (95% CI, 0.51 to 0.53), 0.82 (CI, 0.81 to 0.83), 1.51 (CI, 1.45 to 1.56), and 1.61 (CI, 1.58 to 1.64), respectively. The relative cash prices for brand-name drugs were 0.97 (CI, 0.96 to 0.97), 1.00 (CI, 0.99 to 1.00), 1.06 (CI, 1.05 to 1.08), and 1.03 (CI, 1.02 to 1.04), respectively., Limitation: Results may not reflect current drug prices and do not account for point-of-sale discounts or price matching that may be offered by smaller pharmacies., Conclusion: Compared with large chains, independent pharmacies and small chains had the highest cash prices for generic drugs and big box pharmacies the lowest. Relative differences in cash prices for brand-name drugs were modest across types of retail pharmacies., Primary Funding Source: Arnold Ventures.

Introduction: Excess spending and poor quality in the US healthcare system has led to proliferation of performance-based payment models. These models have the potential to enhance value by creating a meritocratic system whereby providers delivering the best patient care are rewarded, while providers failing to provide such care are given incentives to improve. However, early experience suggests that unless these systems are appropriately designed, payments can be withheld from high performers, bonuses paid to low performers, and health disparities can be worsened. Performance-based payments are new to community pharmacies, and opportunity exists to strengthen pharmacy value measurement and potentially avoid problems observed with other performance-based payment models., Model Construction and Application: This article describes the process by which a framework to assess community pharmacy value was developed, then applies the framework to produce a draft composite pharmacy performance measure. The pharmacy value framework addresses potential shortcomings of existing community pharmacy performance measures through four key principles: 1) theory-based quality and spending measures, 2) scoring which accounts for measure reliability, 3) full risk-adjustment, and 4) a value matrix to identify high and low value pharmacies. Based on these principles, a draft community pharmacy composite performance measure was developed, and was successful in dividing community pharmacies into high, typical, and low value categories., Conclusion: By using this framework to develop future composite measures, payers may find closer alignment between performance-based payments and actual pharmacy performance. This early work is intended to encourage further research into the establishment of a scientifically firm foundation for pharmacy performance measurement. More testing is needed to determine reliability, validity, and comparative superiority of any composite measure derived from this framework before it is used to support performance-based pharmacy payment models., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The 340B Drug Pricing Program, created by Congress in 1992 through the Veterans Health Care Act, has provided discounted drug prices to hospitals and other health care organizations serving a wide population of low-income patients. Some 340B programs use contract pharmacies, an arrangement whereby the hospital or health care organization signs a contract directly with a pharmacy to provide covered pharmacy services at discounted prices. The federal 340B Drug Pricing Program has provided access to reduced price prescription drugs to more than 35 000 individual health care facilities and sites certified by the US Department of Health and Human Services, and clinics have served more than 10 million people in all 50 states, plus commonwealths and US territories. The 340B program has increased profits for hospitals through contract pharmacies because they have still received the same reimbursement but acquired drugs at a lower rate.

Background: Opioid prescription patterns, including long-term use, multiple prescribers, and high opioid doses, increase the risk for adverse outcomes; however, previous research in older adult populations has primarily described opioid dose patterns using average daily dose measures or using very high thresholds (i.e., > 100 morphine milligram equivalents [MME] per day)., Objective: To describe prescription patterns by peak dose among older adults who have newly initiated opioid use in 2014 and describe long-term opioid use and the use of multiple pharmacies and prescribers among those with peak opioid doses over 50 and over 90 MME per day., Methods: This was a retrospective cohort study of Medicare Part D prescription claims data (5% sample) for beneficiaries aged 65 years and older who were prescribed ≥ 1 opioid prescription in 2014 and did not have an opioid prescription in the preceding 180 days. Within a 1-year period of follow-up, we used prescription claims to characterize individuals' opioid exposure, measuring long-term opioid use (≥ 90 days of continuous opioid supply), unique opioid prescribers, and unique opioid-dispensing pharmacies. Peak MME was defined as the maximum daily MME received across all overlapping opioid prescriptions in the observation period., Results: 144,127 beneficiaries without an opioid prescription in the previous 6 months filled ≥ 1 opioid prescription in 2014. During the 1-year follow-up period, 6.5% of beneficiaries transitioned to long-term opioid use; 39.5% received opioid prescriptions from > 1 prescriber; 18.1% filled opioid prescriptions from > 1 pharmacy; and 21.8% had a peak MME of 50-89. Among the 28.1% of beneficiaries exposed to a peak MME > 50, 8.6% developed long-term opioid use; 7.0% had 3 or more opioid dispensing pharmacies; and 28.0% had 3 or more opioid prescribers. Among the 6.2% of beneficiaries exposed to a peak MME ≥ 90, 18.5% developed long-term opioid use; 13.0% had 3 or more opioid dispensing pharmacies; and 39.6% had 3 or more opioid prescribers., Conclusions: High doses of opioids were prescribed for about one quarter (28%) of Medicare beneficiaries with new opioid use in 2014. Having multiple opioid prescribers or multiple opioid dispensing pharmacies was common, especially among those prescribed higher doses. These prescription patterns can be particularly helpful to identify older adults with increased opioid-related risk., Disclosures: No funding supported this study. Raman reports research grants from GlaxoSmithKline not related to this study. Roberts was supported by a CTSA grant from NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research (#KL2TR000119). The other authors have no potential conflicts to report.

Background: This study summarizes the potential financial impact of a 3-year collaboration focused on delivering disease management services through pharmacies in 12 rural Colorado communities., Objectives: To (a) identify components within the disease management program that would be billable and generate revenue to each pharmacy and (b) estimate the revenue amount that could be generated based on these services across the 3-year project., Methods: Reimbursable services included diabetes self-management education; medication therapy management services, including the comprehensive medication review; and improvements in Medicare star ratings through pharmacy interventions., Results: An estimated total of $117,800 could have been generated by services provided to patients across the 12 pharmacy sites. After subtracting the estimated cost of labor for a pharmacist to provide these services, an estimated net profit of $60,023 resulted over 3 years. Star rating impacts were discussed but were not able to be included as specific revenue based on the complex contracting between pharmacies and third-party insurers., Conclusions: Based on these estimates, delivery of chronic disease management could represent a financially feasible option for community pharmacists. Some credentialing and changes to the mode of delivery would be required to meet billing requirements. Further research is needed to better estimate the cost savings resulting from these services to possibly expand pharmacists' reimbursement opportunities., Disclosures: This publication was supported by Cooperative Agreement Number DP004796-05, funded by the Centers for Disease Control and Prevention. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. None of the authors have any conflicts of interest to disclose regarding this work.

Background and objectives : Extemporaneous preparations are pharmaceutical preparations individually prepared for a specific patient or patient group, but also high-risk products accompanied by doubts regarding their safety and quality. Legislation regulating the compounding of extemporaneous preparations is not harmonized among European countries. This problem is partially resolved by Resolution CM/Res(2016)1 on quality and safety assurance requirements for medicinal products prepared in pharmacies for the special needs of patients. In order to understand the relevance of extemporaneous compounding in Latvia and the fulfillment of the abovementioned resolution's requirements, it is essential to get information about the volume and breakdown of sales of extemporaneous medicinal products in community pharmacies. The purpose of this survey is to identify the sales volume of extemporaneous preparations in community pharmacies in Latvia in 2017 by analyzing unpublished data of the State Agency of Medicines (SAM), as well as comparing Latvian laws with the requirements of the resolution. Materials and Methods : A separate Microsoft Excel spreadsheet was prepared for each statistical region in order to summarize the unpublished information of SAM on the turnover of extemporaneous preparations in 2017 in all Latvian statistical regions. In order to compare the regulatory framework in Latvia with the resolution, the Latvian Pharmaceutical Law and the Cabinet of Ministers Regulations regulating prescription, compounding and control of extemporaneous preparations in community pharmacies were analyzed. Results : Only 280 of 384 pharmacies submitted a report of sales of extemporaneous preparations for 2017 to the SAM. These pharmacies represented all Latvian statistical regions. Extemporaneous preparations were mostly sold in Riga (78.93%). The Latvian regulation does not include all paragraphs of the resolution. Most of the paragraphs of the resolution are described in Latvian regulatory enactments only partially. Conclusions : The total number of compounding pharmacies evidence that the service is needed. Latvian example highlights a necessity for European Union countries to compare their national legislation with the requirements of the resolution's last version and, if necessary, implement relevant amendments.

Objective: To estimate the own-price elasticity of demand for naloxone, a prescription medication that can counter the effects of an opioid overdose, and predict the change in pharmacy sales following a conversion to over-the-counter status., Data Sources/study Setting: The primary data source was a nationwide prescription claims dataset for 2010-2017. The data cover 80 percent of US retail pharmacies and account for roughly 90 percent of prescriptions filled. Additional covariates were obtained from various secondary data sources., Study Design: We estimated a longitudinal, simultaneous equation model of naloxone supply and demand. Our primary variables of interest were the quantity of naloxone sold, measured as total milligrams sold at pharmacies, and the out-of-pocket price paid per milligram, both measured per ZIP Code and quarter-year., Data Collection/extraction Methods: Primary data came directly from payers and processors of prescription drug claims., Principal Findings: We found that, on average, a 1 percent increase in the out-of-pocket price paid for naloxone would result in a 0.27 percent decrease in pharmacy sales. We predict that the total quantity of naloxone sold in pharmacies would increase 15 percent to 179 percent following conversion to over-the-counter status., Conclusions: Naloxone is own-price inelastic, and conversion to over-the-counter status is likely to lead to a substantial increase in total pharmacy sales., (© 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Background: The Biologics Price Competition and Innovation Act (BPCIA) of 2009, which included pathways for FDA approval of biosimilar products, was designed to promote more affordable, expanded patient access to biologic therapies. Achieving these BPCIA goals depends on overcoming formidable barriers to biosimilar adoption. Managed care and specialty pharmacy professionals are uniquely qualified to inform initiatives to address these barriers., Objective: To assess perceptions regarding strategies for overcoming barriers to biosimilar adoption among managed care and specialty pharmacy professionals by conducting a survey study., Methods: Invitations to complete the online survey were emailed by the Academy of Managed Care Pharmacy (AMCP) to members and customers and to contacts sourced from a commercial database. In addition to questions on respondent demographics and perceptions of biosimilars, the survey listed 16 strategies for overcoming key barriers to biosimilar adoption. On a 5-point scale, participants rated their opinion on the likelihood that each strategy would have the potential to assist in achieving BPCIA goals. The survey also listed 6 barriers to biosimilar adoption. On a 5-point scale, participants rated their perceived difficulty in overcoming each barrier. The survey concluded with an open-text item that asked participants to list 3 additional strategies for overcoming biosimilar adoption barriers. Response frequencies were calculated to describe participants' ratings of the strategies and barriers. Statistical analyses were conducted to assess whether the ratings differed among respondents grouped by work organization. For the open-text item, we conducted qualitative content analyses to categorize strategies by stakeholder groups that might take primary implementation roles., Results: A total of 300 managed care and specialty pharmacy professionals completed the survey. There was considerable variation in the preferences, policies, and practices regarding biosimilar adoption among respondents' work organizations. Responses to several survey items reflected positive attitudes about the safety and efficacy of biosimilars; for example, 84% agreed or strongly agreed that FDA-approved biosimilars are safe and effective for patients who switch from a reference biologic. Based on pooled percentages for ratings of likely and extremely likely to overcome barriers to biosimilar adoption, the highest-rated strategies were for prescriber education about evidence from switching studies (91%) and FDA guidance on pharmacy-level substitution of reference biologics with biosimilars (90%). The lowest-rated strategies were for requiring therapeutic drug monitoring for patients who switch to biosimilars (39%) and using quotas to incentivize providers to prescribe biosimilars (40%). For the qualitative analysis, the highest numbers of respondents' suggested strategies indicated primary implementation roles of biosimilar manufacturers (40%), the federal government (26%), and managed care organizations (15%)., Conclusions: Reflecting the unique knowledge, perspectives, and practices of managed care and specialty pharmacy professionals, the study findings are relevant to informing and advancing initiatives for achieving BPCIA goals., Disclosures: The survey study reported in this article was part of a continuing education program funded by an independent educational grant, which was awarded by Sandoz, a Novartis Division, to PRIME Education. The Academy of Managed Care Pharmacy (AMCP) received grant funding from PRIME to assist in developing the survey and writing the manuscript. The grantor had no role in the study design, execution, analysis, or reporting. Greene and Pardo are employed by PRIME. Singh and Carden are employed by AMCP. Greene, Singh, Carden, and Pardo have no other disclosures. Lichtenstein received an honorarium from PRIME for serving as faculty for the continuing education program and has been a consultant for Pfizer, Cellceutix, and Merck.

Objective: To evaluate the economic and clinical impact of community pharmacist-led pharmacy benefit management (PBM) services., Setting: Independent community pharmacy in western North Carolina., Practice Description: Sona Benefits is a PBM partner to self-funded plans in western North Carolina. The services provided by Sona Benefits are led by pharmacists at its affiliate company, Sona Pharmacy + Clinic., Practice Innovation: In October 2016, Sona Benefits began providing PBM services to members employed by a local continuing care retirement community., Evaluation: Economic outcome measures included change in total medical and prescription costs per member per year (PMPY) and change in cost per prescription from baseline. Change in clinical outcome measures (hemoglobin A1C, weight, blood pressure) was assessed for members who participated in 2 or more quarterly health coaching sessions., Results: Prescription costs were reduced from $1219.72 to $858.57 PMPY and medical health care costs were reduced from $5910.76 to $4290.30 PMPY from baseline. This represented a total decrease of $1981.61 PMPY in health care costs. A reduction in the average cost per prescription from $95.10 to $61.88 was observed. For patients enrolled and active in health coaching, we observed reductions in weight, hemoglobin A1C, and blood pressure. Between the initial and final health coaching visits, average weight decreased from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg), the percentage of patients at hemoglobin A1C goal increased from 47% to 53%, and percentage of patients at goal for blood pressure increased from 58% to 78%., Conclusion: Inclusion of community pharmacists in PBM service delivery produced economic benefits for plan sponsors. Preliminary clinical data suggested benefits of pharmacist-led health coaching services, but further evaluation is needed to determine the long-term impact., (Copyright © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)