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ObjectiveTo determine whether there was an increase in payments for neurologist-prescribed drugs, we performed a retrospective analysis of prescription claims in the Medicare Part D Prescriber Public Use Files from 2013 to 2017.MethodsWe included claims prescribed by providers with the taxonomy “neurology” and included drugs present in all 5 years. Drugs were designated in 2013 as generic (GEN), brand name only (BNO), and brand name prescribed even though a generic equivalent is available (BNGE). To observe payment trends, the percentage change in the per claim payment was compared between drug classes.ResultsWe included 520 drugs, of which 322 were GEN, 61 were BNO, and 137 were BNGE, representing 90,716,536 claims and generating payments of $26,654,750,720. While the number of claims from 2013 to 2017 increased only 7.6%, the total payment increased 50.4%. Adjusted for inflation, claim payments for GEN drug increased 0.6%, compared to significant increases in BNO and BNGE drugs of 42.4% and 45.0% (ptrend < 0.001). The percentage of overall GEN claims increased from 81.9% to 88.0%, BNO increased from 4.9% to 6.2%, and BNGE decreased from 13.3% to 5.8%. Neuroimmunology/multiple sclerosis drugs represented >50% of the total payments despite being only 4.3% of claims.ConclusionsPayments for neurologist-prescribed brand name, but not generic, drugs in Medicare Part D increased consistently and well above inflation from 2013 to 2017. Unless the overall trend stabilizes or is reversed or high cost-to-claim drugs are addressed, this trend will place an increasing burden on the neurologic Medicare budget.

Background Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer. Methods Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes. Results We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P P Conclusion Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors.

BACKGROUND: Utilization of systemic IV tPA in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. We describe the frequency and types of tPA administration errors made in a comprehensive stroke center (CSC) and at stroke receiving facilities prior to transfer. METHODS: Using a prospectively-collected stroke quality database, all patients included received IV tPA from 2010-11 either at the CSC or prior to transfer (“drip-and-ship”). Retrospective data collection included pharmacy, air transport, and nursing records. RESULTS: We identified 131 tPA-treated AIS cases: 51% female; mean age 68 years; 33% treated at CSC; and 67% treated pre-transfer (including 16% by telestroke) from 22 facilities. Treatment of stroke mimics was more common at the CSC (12% vs 9%, p=NS). Pre-tPA blood pressure was more frequently not recorded in transfers (64% vs 7%, p 60 minutes (14%), total dose >90mg (5%), suspension/discontinuation of infusion (5%), or delayed tPA delivery to bedside (4%). Body weight discrepancies between institutions were frequent among transfers (42%). Parenchymal hematomas (PH) occurred in 7.5% of all patients (or 6.2% with tPA errors, 9.1% without errors); in-hospital death occurred in 10.7% overall (or 9.2% with errors, 12.1% without errors). PH, mortality and mRS did not differ between CSC-treated patients and transferred patients nor between those with and without errors. See table. CONCLUSION: tPA errors were very common in our large, regional stroke system, particularly among patients treated as “drip-and-ships”. Though in this study errors were not associated with outcomes, CSCs should include tPA dosing/administration education and quality assurance mechanisms within their systems in order to reduce avoidable, systematic errors.

*Guidelines have been published for management of chronic systolic heart failure to reduce patient morbidity and mortality. Objective: A quality review of the heart failure medical therapy for a community family medicine residency program clinic and a multidisciplinary heart failure specialty clinic was performed to compare adherence to ACC/AHA heart failure guidelines, with regard to medications and in titrating to recommended target doses. Methods: The study was a retrospective chart review and data collected included name and dose of any ACEI, beta-blocker, ARB, or other medication addressed in the guidelines. Results: Specialty clinic patients had significantly lower systolic blood pressures and ejection fractions. Significantly more patients were prescribed beta-blockers in the specialty clinic population (98% vs 80%, p

Authors’ response to “Tranexamic acid and uremic bleeding: evidence-based treatment recommendations”