By Kate H. Gamble, Senior Editor

Editor's Note: In recognition of World Breastfeeding Week, we've provided current information on the benefits of breastfeeding and the importance of providing adequate support for patients, along with links to more resources.

Despite the fact that breastfeeding protects against childhood obesity, less than 4% of US hospitals provide the full range of support mothers need to be able to breastfeed, according to a 

 from the CDC. Improving rates of breastfeeding by providing better hospital support to mothers and infants can lead to better overall health in children, including a reduced risk of childhood obesity, the organization stated.

“Hospitals play a vital role in supporting a mother to be able to breastfeed,” said CDC Director Thomas R. Frieden, MD, MPH. “Those first few hours and days that a mom and her baby spend learning to breastfeed are critical. Hospitals need to better support breastfeeding, as this is one of the most important things a mother can do for her newborn. Breastfeeding helps babies grow up healthy and reduces health care costs.”

CDC’s national survey of Maternity Practices in Infant Nutrition and Care

		Only 14% of hospitals have a written, model breastfeeding policy;

		In nearly 80% of hospitals, healthy breastfeeding infants are given formula when it is not medically necessary, a practice that makes it much harder for mothers and infants to learn how to breastfeed and continue breastfeeding at home;

		Just one-third of hospitals practice rooming in, which helps mothers and infants learn to breastfeed by enabling frequent opportunities to attempt it;

		In nearly 75% of hospitals, mothers and infants do not get the support they need when they leave the hospital, including a follow-up visit, a phone call from hospital staff, and referrals to lactation consultants, WIC, and other important support systems in their community.

CDC’s mPINC survey measures the percent of US hospitals with practices that are consistent with the WHO/UNICEF Ten Steps to Successful Breastfeeding. This list of proven hospital practices that increase rates of breastfeeding by providing support to mothers is the core of the Baby-Friendly Hospital Initiative and is endorsed by the American Academy of Pediatrics. The steps include:

		Not giving healthy, breastfeeding infants food or drink other than breast milk unless there is a medical need for it;

		Encouraging mothers to room in, staying with their baby 24 hours a day;

		Connecting mothers with support groups and other resources to help with breastfeeding after they leave the hospital.

“In the United States most women want to breastfeed, and most women start,” said Ursula Bauer, PhD, MPH, director of CDC's National Center for Chronic Disease Prevention and Health Promotion. “But without hospital support many women have a hard time continuing to breastfeed, and they stop early. It is critical that hospitals take action to fully support breastfeeding mothers and babies so they can continue to breastfeed long after their hospital stay.”

Breastfeeding Decreases Risk of Type 2 Diabetes

AAP Policy on Breastfeeding and Use of Human Milk

Articles

Despite the fact that breastfeeding leads to better overall health and fewer doctor visits and prescriptions, mothers aren't getting the support they need.

Support for Breastfeeding Moms Lacking, Says CDC

The US Department of Health and Human Services (HHS) has unveiled guidelines that require new health insurance plans to cover women’s preventive services such as well-woman visits, breastfeeding support, domestic violence screening, and contraception without charging a co-payment, co-insurance or a deductible.

“The Affordable Care Act helps stop health problems before they start,” said HHS Secretary Kathleen Sebelius in a 

. “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”

A significant number of Americans don’t receive the preventive health care they need to maintain good health, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. In fact, HHS estimates that Americans use preventive services at about half the recommended rate, with cost being a top factor.

In 2010, HHS released new insurance market rules under the Affordable Care Act requiring all new private health plans to cover several evidence-based preventive services like mammograms, colonoscopies, blood pressure checks, and childhood immunizations without charging a copayment, deductible or coinsurance. The Affordable Care Act also made recommended preventive services free for individuals on Medicare.

The new guidelines take it a step further by ensuring that women have access to a full range of recommended preventive services without cost sharing, including:

		Human papillomavirus (HPV) DNA testing for women 30 years and older;

		Sexually-transmitted infection counseling;

		Human immunodeficiency virus (HIV) screening and counseling;

		FDA-approved contraception methods and contraceptive counseling;

		Breastfeeding support, supplies, and counseling; and

		Domestic violence screening and counseling.

New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012. The rules governing coverage of preventive services, which allow plans to use reasonable medical management to help define the nature of the covered service, apply to women’s preventive services. Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.

The administration also released an amendment to the prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception.

Previously, preventive services for women had been recommended one-by-one or as part of guidelines targeted at men as well. As such, the HHS directed the Institute of Medicine (IOM) to conduct a scientific review and provide recommendations on specific preventive measures that meet women’s unique health needs and help keep women healthy.

To access the IOM report—Clinical Preventive Services for Women: Closing the Gaps&mdash;click 

For more information on the HHS guidelines, click 

New guidelines established as part of the Affordable Care Act ensure that women receive preventive health services at no additional cost.

Insurers Must Cover Birth Control, Other Preventive Services

A pair of studies looking at mail-order pharmacy may shed some light on the question of what method of obtaining medications can yield the best outcomes for patients.

, published online ahead of print in the 

, Kaiser Permanente Northern California patients who obtained new statin prescriptions via a mail-order pharmacy achieved better cholesterol control in the first 3 to 15 months after initiating therapy compared to those who purchased their statin prescription from a local pharmacy. Lead author Julie Schmittdiel, PhD, and colleages determined that greater adjusted rates of LDL cholesterol control in mail-order pharmacy users were seen across all gender and race-ethnicity groups.

After adjustment for demographic, clinical, and socioeconomic characteristics, as well as for potential unmeasured differences between mail-order and in-person pharmacy users, 85% of patients who used the mail-order pharmacy achieved target cholesterol levels, compared to 74.2% of patients who only used the local Kaiser Permanente pharmacy.

“While the findings of this study should be confirmed in a randomized controlled trial, they provide new evidence that mail-order pharmacy use may be associated with improved care and outcomes for patients for risk factors with cardiovascular disease,” Schmittdiel said. “Though mail order may not be right for all patients, this study shows that it is one possible tool in the broader health care system-level toolbox that can help patients meet their medication needs.”

suggest that patient choice may play a role in adherence. In comparing adherence rates under voluntary and mandatory mail benefit designs, a group of researchers led by Joshua N. Liberman, PhD, of Geisinger Health System found “mandatory mail appears to cause some members to discontinue therapy prematurely, particularly those without previous mail-service pharmacy experience.”

Liberman and colleagues compared adherence rates in the first year of therapy between voluntary and mandatory mail cohorts composed of individuals who initiated statin, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, platelet aggregation inhibitor, metformin, glitazone, or sulfonylurea therapy at a retail pharmacy between January 1 and March 31, 2009.

They found that although persistence rates were similar through the first 60 days of therapy, the mandatory mail cohort had a notable drop in persistence by day 90 (63.3% vs 56.3%), with a more pronounced drop among those without previous mail-service pharmacy use (50.5%).

“Offering a mail-service pharmacy option is an important benefit design tool that helps to control pharmacy costs and may facilitate medication adherence among those who successfully transition to 90-day-supply prescriptions,” the authors wrote. “However, restricting pharmacy choice by requiring the transfer of prescriptions from retail to mail-service pharmacy causes some members to discontinue therapy early. When members choose to eschew therapy rather than switch to a lower cost alternative, the unintended consequence is a reduction in medication adherence and the potential for increased medical expenses.”

 that looked at both studies, George Van Antwerp, vice president of the Solutions Strategy Group at Silverlink Communications, wrote that if patients are required to move to a 90-day mail-order prescription, “it's important to have a clear transition path for them so that they (a) understand their benefit; (b) realize how to move; and (c) don't end up simply missing refills or stopping therapy.”

Two new studies show that although mail-order pharmacy can increase medication adherence, patient choice in the matter is a key factor.

Can Mail-Order Pharmacy Improve Medication Adherence?

Cost may be important, but when it comes to choosing a drugstore, quality service is still the top priority for patients.

New research from 3 large-scale surveys shows that despite an increased sensitivity to cost issues—particularly in the past year&mdash;patient satisfaction hinges largely on factors like pharmacist knowledge about drugs and other products, helpfulness, speed, accuracy, and personal service. And the places that rank highest in these areas are independent drugstores.

 found that 94% of readers are highly satisfied with their experiences at neighborhood independent drugstores, which ranked first in areas including quick counter service, reliability with medication pick-up, medication accuracy, and accessibility to pharmacists. The Medicine Shoppe and Health Mart, independent-like chains that are individually owned and operated but have a common parent company, were included in this group.

According to the report—in which 43,739 readers rated their experiences buying prescription drugs at walk-in chain, independent, supermarket, and mass-merchandise stores&mdash;22% said that they fill their prescriptions at big box stores, compared with 14% in 2002, with price cited as a key factor in the decision. In term of service, however, several issues arose. One in 4 mass merchant shoppers complained of a long wait at the service counter; 33% said they waited for 2 or more days to get a prescription if a drug was out of stock; 15% reported that an order wasn’t ready when promised; and 4% claimed they received the wrong number of pills.

The stores that were most likely to be out of stock, according to 

, were Albertsons, Jewel-Osco, Smith’s, Stop & Shop, and Winn-Dixie supermarkets. Almost half lacked the medicine that patients needed on at least 1 occasion during the past year. Delays in getting out-of-stock drugs were reported to be longest at Giant Food, which was also cited as having the biggest bottlenecks at the pharmacy counter, along with Walmart and Meijer.

This is significant, as 49% of readers said that the ability to get in and out quickly with medicine in hand was a key consideration in choosing a drugstore.

What’s also important is the fact that many patients go online to comment on their experiences and read what others have written. These conversations, according to the 

J.D. Power and Associates 2010 U.S. National Pharmacy Study

, “tend to revolve around good and bad experiences far more often than the cost paid for the prescription, with the primary complaints being unfriendly pharmacy staff, long wait times and prescription mistakes.”

In today’s ultra-competitive environment, even a little bit of bad publicity can negatively impact a pharmacy’s bottom line. On the other hand, positive comments can go a long way, according to the J.D. Power survey, which found that pharmacy customers who are highly satisfied are 3 times more likely to say they “definitely will” return to their pharmacy and 10 times more likely to say they “definitely will” recommend their pharmacy to others, compared to customers with low satisfaction levels. Based on national average spending by pharmacy customers, a highly satisfied customer may generate $227 in additional prescription revenue each year, the report found.

“Consumers are spending more on health care expenses in general due to various employer-implemented changes in insurance coverage,” said Jim Dougherty, director of the health care practice at J.D. Power and Associates. However, “high-performing pharmacies aren’t necessarily those with the lowest prices. Rather, pharmacies that are focused on service garner the highest levels of satisfaction. Customer service still trumps price, even in an environment where cost has become increasingly important.”

So how can pharmacies improve their service ratings?

One way is through face time, according to data from a 

, which found that patients who had in-depth counseling with a pharmacist were 90% likely to use the pharmacy again in the future and 71% likely to recommend the pharmacy. However, although most patients (80%) consider the service to be important, just 36% have used in-depth counseling, indicating a possible area of focus for patient care incentives. Those who use the service are also more like to make additional store purchases than other customers.

Other findings from the surveys are as follows:

		Supermarket pharmacies came in second to independents in the 

 survey; 84% of readers who bought drugs there reported that they were highly satisfied.

		In the J.D. Power survey, Publix ranked highest among supermarkets in terms of patient satisfaction with a score of 862 out of 1000, followed by Wegmans (859) and Winn-Dixie (853).

 survey, 41% of Americans said that they buy their prescription medicine at traditional chains, which is more than at any other type of drugstore.

		According to J.D. Power, Target ranked highest among mass merchandisers for a fourth consecutive year with a score of 848, while Costco and Sam’s Club followed in a tie, each with 844.

As the role of the pharmacist in providing quality patient care continues to grow, pharmacies of all sizes have an opportunity to offer a higher level of service and become an invaluable resource for patients. 

New survey data show that even in the current financial climate, quality service is more important to patients than low cost.

Independents Rank Highest in Patient Satisfaction

On April 5, 2011, the Centers for Medicare & Medicaid Services (CMS) released a 

 on revisions to Medicare for 2012 and the 

Final 2012 Advance Notice and Call Letter

 on changes to Medicare Advantage and Medicare Part D for 2012.

Pharmacy-related provisions in the final rule include medication therapy management (MTM) programs and short-cycle dispensing in long-term care facilities (LTCFs), according to the American Pharmacist Association (APhA).

In terms of the Medicare Part D MTM programs, the final rule reconciles Affordable Care Act (ACA) provisions with existing regulations that were effective in 2010. The plans’ MTM benefit for targeted beneficiaries must continue to have opt-out enrollment for MTM services in addition to including an annual comprehensive medication review (CMR), targeted medication review, and summary of the patient’s visit, noted Marcie Bough, PharmD, APhA’s Senior Director, Government Affairs, in a 

Effective January 1, 2013, patients receiving a CMR will be provided a Medication Action Plan (MAP) in a standardized format. Plans will also be required to perform a quarterly assessment of all at-risk individuals not already enrolled as a targeted beneficiary in an MTM program. CMS did not finalize MTM-related provisions for LTCFs, and will work with stakeholders on those, according to APhA.

CMS also announced plans to delay implementation of its proposed Medicare Part D long-term care "short-cycle" rule for one year and to modify the requirements to be less onerous for independent pharmacies, according to the National Community Pharmacists Association.

"Medicare officials are doing the right thing for patients and the long-term care pharmacists who serve them," said NCPA Executive Vice President and CEO Douglas Hoey, RPh, in a 

. "Pharmacists are committed to working with Medicare and other health plans to reduce costs, while maintaining quality care. However, there is no creditable evidence that this proposed move to shorter dispensing cycles would reduce costs and, in the end, we fear it could actually increase costs for taxpayers. That's why a broad coalition of lawmakers and health care providers is urging CMS to hold off on the program to allow for data gathering necessary to implement this program intelligently."

In addition to delaying implementation of the short-cycle rule from Jan. 1, 2012 to Jan. 1, 2013, the final rule also would ease the requirements on how LTC pharmacies account for dispensed, but unused, medications. The final rule also requires that LTC pharmacies dispense solid oral doses of brand-name medications in 14-day-or-less supplies, compared to the more onerous 7-day-or-less mandate in CMS' proposed rule.

Prior to the announcement, a number of leaders from health care groups and government officials expressed concerns regarding the merits and justification for the short-cycle rule, and urged CMS to postpone implementation of the rule until a more proper, comprehensive analysis could be conducted.

"This additional time does two important things," Hoey added. "First, it gives CMS more breathing room to fully reconsider this policy. For example, NCPA and others continue to advocate that the agency seek high-quality, unbiased data to fully evaluate the cost impact of the short-cycle rule before moving forward with it. Second, this window gives independent pharmacies and other LTC providers additional time to make the considerable changes in workflow and staffing that may be necessary to comply with the final requirements. We deeply appreciate the support of this broad coalition of lawmakers and health care providers."

Other changes in the final rule to Medicare for 2012 include standardization of the exceptions and appeals process for plans, revisions to the definition of “pharmacist,” payment for multi-ingredient drug compounds, and the continued steps in the closing of the Part D coverage gap.

As part of the final rule, MTM programs must include an annual comprehensive medication review, targeted medication review, and patient visit summaries.

Changes for MTM, Short-cycle Dispensing Included in Medicare Revisions

Editor's Note: In recognition of IBS awareness month, we've provided current information on drug treatments for the condition, along with links to more resources. 

For years, irritable bowel syndrome (IBS) has been a thorn in the side of patients, physicians, and pharmacists.

Defined as a gastrointestinal disorder characterized by recurring symptoms of abdominal pain, bloating, and altered bowel function in the absence of structural, inflammatory, or biochemical abnormalities, IBS is difficult to diagnose and often doesn’t respond to treatment.

For patients, learning how to manage the condition can be an ordeal. However, findings from 

 may offer hope for those who suffer from IBS.

Research has shown that IBS patients make more visits to physicians, undergo more diagnostic tests, are prescribed more medications, miss more workdays, have lower work productivity, are hospitalized more frequently, and account for greater overall direct health care costs than patients without the condition, according to the American College of Gastroenterology.

All of this can have a severe impact on quality of life, making it all the more critical that the condition is properly treated.

The problem is that IBS is a symptom complex. Because no reliable markers have been identified, the effects of pharmacotherapy are typically assessed by asking patients to report whether their symptoms were adequately relieved.

IBS, as many pharmacists can attest, can be challenging.

Current pharmacologic treatments—which include antispasmodics, antidepressants, antidiarrheals, serotonin reuptake inhibitors, probiotics, antibiotics, over-the-counter supplements, laxatives, complementary and alternative treatments, and lifestyle changes&mdash;are aimed at relieving the predominant GI symptom. The goal, however, should be to improve overall symptoms, including altered stool frequency and consistency, abdominal pain and discomfort, bloating, and quality of life.

This is where most treatments fall short, according to the authors of the NEJM study, who conducted 2 investigations to determine the efficacy of the antibiotic rifaximin (Xifaxan) as a treatment for IBS.

Lead author Mark Pimentel, MD, of Cedars-Sinai Medical Center in Los Angeles, CA, and colleagues hypothesized that gut flora may play a key role in the pathophysiology of IBS. In 2 identically designed, phase 3, double-blind, placebo-controlled trials, patients who had IBS without constipation were randomly assigned to either rifaximin at a dose of 550 mg or placebo, three times daily for 2 weeks, and were followed for an additional 10 weeks. The primary endpoint was the proportion of patients who had adequate relief of global IBS symptoms, while the key secondary endpoint was the percentage of patients who had adequate relief of IBS-relating bloating.

The investigators found that significantly more patients in the rifaximin group than in the placebo group had adequate relief of global IBS symptoms during the first 4 weeks after treatment, and that more patients in the rifaximin group had adequate relief of bloating. In addition, significantly more patients in the rifaximin group had a response to treatment as assessed by daily ratings of IBS symptoms, bloating, abdominal pain, and stool consistency.

“These results support the idea that intestinal microbiota or gut bacteria may be an underlying cause of IBS, and altering gut bacteria by treatment with rifaximin appears to be an effective way of providing relief to those who suffer from IBS symptoms,” said Yehuda Ringel, MD, an associate professor of medicine in the UNC School of Medicine and a co-author of the studies, in a 

The authors also noted that the antibiotic effect of rifaximin is most likely responsible for its efficacy in reducing the symptoms of IBS. Although there is some debate over which antibiotic effect is most important, they believe that rifaximin appears to target the cause of IBS rather than just treating the symptoms—a finding that could have significant implications for the treatment of IBS patients.

Although these studies offer promising data, it is important to remember that because of the complexities involved in diagnosing and treating IBS, there are still many patients who opt for self-treatment, often with OTC products. The role of the pharmacist in determining whether self-treatment is appropriate, and advising patients with IBS about the use of medications to treat their symptoms, is critical.

Counseling Tips for Patients with Irritable Bowel Syndrome

Is Childhood Abdominal Pain Linked to Adult IBS?

In the video below, Larry Schiller, MD, a gastroenterologist based in Dallas, Texas, discusses the mechanism and effectiveness of several treatment options for IBS, including fiber therapy, antispasmodic drugs, lubiprostone, alosetron and anti-depressant drugs.

New data suggest that altering gut bacteria may be the key to providing relief for IBS, a disorder that continues to perplex both pharmacists and patients.