[Show abstract][Hide abstract] ABSTRACT: Therapeutic interchange (TI) interventions are commonly used to manage pharmacy benefit costs. While several studies have considered the effect that TI interventions have on drug costs, most have not considered the effect they have on medical management costs. The purpose of the present study was to assess drug cost and drug therapy management costs of a TI intervention following a change in the drug formulary for 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) drugs, including the conversion of atorvastatin from formulary to nonformulary status.
A retrospective, quasi-experimental within-subjects design was used in this study. Administrative claims data were obtained from a select northeastern segment of a multistate Medicaid managed care organization (MCO). To be included in the study, patients had to meet the following criteria: (1) they must have had a minimum of 3 atorvastatin prescriptions during a 6-month enrollment phase, (2) they must have been continuously enrolled throughout the 900-day study period, and (3) they must have switched from atorvastatin to another statin between April 1, 2003, and July 31, 2003. The day of the switch from atorvastatin marked for each patient the end of the 12-month pre-TI period and the beginning of the 12-month post-TI period. Two separate dependent variables were developed: (1) statin drug costs (statin cost + dispensing fee) and (2) the costs paid by the MCO for the medical management of statin therapy, including office visit costs and the medical laboratory costs of measuring lipids and creatine kinase, and of checking liver functions. To estimate expenditures over 24 months, a panel analytic technique was used that allows each patient to serve as his or her own control. Multivariate models were used to assess the effects of the TI policy while controlling for age, gender, adjunctive dyslipidemia therapy, comorbidity, presence of a prior coronary artery event, statin compliance, cardiologist management, and disease severity.
Of the 3,636 patients who met the study inclusion criteria and were converted from atorvastatin to an alternate statin drug, 129 patients (3.5%) switched back to atorvastatin following the TI. The average statin cost per claim in the 12-month post-TI period was Dollars 70.93, 9.5% less than the average cost in the 12-month pre-TI period (Dollars 78.40). The average cost per patient per year (PPPY) for statin laboratory tests (lipid panels, creatine kinase tests, and liver function tests) increased by 31.5% to Dollars 16.15 in the post-TI period compared with Dollars 12.28 PPPY in the pre-TI period, and medical office visit costs increased by 44.9% to Dollars 20.70 PPPY in the post-TI period compared with Dollars 14.29 PPPY in the preperiod. These increased costs related to the medical management of statin therapy were overwhelmed by an 11.7% reduction in statin drug costs, from Dollars 793.69 PPPY in the pre-TI period to Dollars 701.01 PPPY in the post-TI period, resulting in a net 10.0% reduction for combined statin costs and related medical costs, from Dollars 820.27 PPPY in the pre-TI period to Dollars 737.87 in the post-TI period. After limiting the analysis to patients who did not convert from atorvastatin to pravastatin (which cost more than atorvastatin before the rebate) and controlling for the influence of potential confounders, statin expenditure decreased by 33% (P < 0.001). Multivariate models indicated no statistically significant differences in the costs related to the medical management of statin therapy after the TI compared with before the TI.
Journal of managed care pharmacy: JMCP 06/2006; 12(4):331-40. · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the quality gap in health care as it was referred to in the Institute of Medicine's reports, to try to harness pharmacy's potential to improve the quality of drug therapy, and to provide insight into the elusive leadership, management, and dynamics of change.
Current health care is nowhere near ideal. Successful quality initiatives have included establishing a "culture of quality" (promoting a learning organization), having good leadership, and developing strong management. Ideally, all of these concepts must be applied concurrently for the best results because using only one will not spirit medicine across the gap. To close the gap, pharmacists need to understand various types of change and select a change mechanism that will continuously improve care.
Optimizing drug therapy is both a great challenge and a great opportunity for pharmacy. AMCP's Framework for Quality Drug Therapy is a continuous quality improvement model that gives us the tools to plan, implement, and evaluate strategies to improve the quality of patient care and cross the "quality chasm."
Journal of managed care pharmacy: JMCP 03/2005; 11(2 Suppl):S10-3. · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Migraine is a common disorder that costs US employers billions of dollars each year in missed workdays and reduced productivity. Seven triptans, including almotriptan and rizatriptan, are recommended as first-line therapy for acute migraine.
The aim of this study was to assess the relative cost-effectiveness of almotriptan and rizatriptan in the treatment of acute migraine.
A model was built to compare almotriptan 12.5 mg and rizatriptan 10 mg for the treatment of a single, acute migraine attack. Cost-effectiveness (in year-1999 US dollars) was evaluated from the perspective of a US health care payer. Mean and incremental cost-effectiveness ratios (CERs) were calculated. The effectiveness measure was the proportion of patients who achieved sustained freedom from pain with no adverse events (SNAE). Data on sustained pain-free outcomes and adverse-event rates were obtained from a meta-analysis of oral triptan trials. Efficacy and tolerability were assumed to be independent in the base-case scenario, so the total direct cost of treating a single migraine attack was calculated, adding drug costs to health service costs per attack.
In the base-case analysis, the mean CERs for almotriptan 12.5 mg and rizatriptan 10 mg were 91.12 dollars and 131.26 dollars, respectively, per attack at which SNAE was achieved after treatment. The incremental CER for almotriptan (compared with rizatriptan 10 mg) was 6.94 dollars per additional SNAE achieved. The economic benefit of almotriptan 12.5 mg was robust in a range of sensitivity analyses.
Almotriptan 12.5 mg was more cost-effective than rizatriptan 10 mg for the treatment of acute migraine in this analysis based on published data.
[Show abstract][Hide abstract] ABSTRACT: This chapter explores the potential economic effects of pharmacogenomics at the individual, health care provider, and producer levels. To assess the value of pharmacogenomic-based drugs, one must evaluate not only the clinical but also the economic and humanistic cost and consequences of treatment. Pharmacogenomics has the potential to change the outcomes of many highly morbid or even fatal conditions; conditions that generate enormous economic costs not only in terms of actual expenditure, but also in human suffering and lost productivity. Issues of access, cost and quality will emerge as these new regimens become available.
[Show abstract][Hide abstract] ABSTRACT: Three years of data from the National Ambulatory Medical Care Survey were analyzed to assess resource utilization for patients with irritable bowel syndrome (IBS), asthma, and migraine. Adjusted for prevalence, IBS-related physician visits occurred at approximately the same rate as those for asthma and 2.6 times the rate of visits for migraine. Specialist consultations for IBS were of similar frequency to those for migraine and more frequent than those for asthma. Diagnostic and screening tests were ordered more often during IBS-related visits than during migraine- or asthma-related visits. Prescription rates were similar for all three conditions. In terms of resource consumption, this chronic disorder places a burden on patients that is comparable with that of such costly conditions as asthma and migraine.
[Show abstract][Hide abstract] ABSTRACT: Sound, informed decision making regarding which drugs to include on a formulary should be based on the best available evidence of their clinical efficacy and incidence of adverse events. Comparative drug costs and clinical effectiveness should also be considered during the formulary development process. Clinical trials traditionally evaluate efficacy and adverse events independently, whereas effectiveness in real-life conditions is defined as some combination of efficacy and side effects. When evaluating similar medications, head-to-head efficacy and effectiveness studies are preferred. For oral triptans (serotonin 5-HT(1B,1D) receptor agonists), there are many placebo-controlled trials and several active trials that compare newer oral triptans with sumatriptan; however, there have been few comparisons of triptans in head-to-head trials. Meta-analysis is an appropriate method to evaluate multiple clinical trials critically and combine the results. A recently published meta-analysis used patient-level data to assess efficacy and adverse events across multiple triptan clinical trials. In this analysis, we combined those results with medication costs to assess the overall value among oral triptans. Using this combined approach, almotriptan was found to have the greatest economic value. It delivers comparable efficacy, placebo-like tolerability, and the highest value when compared with other triptans currently marketed in the United States.
The American journal of managed care 03/2002; 8(3 Suppl):S80-4. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To determine whether the increased acquisition costs associated with the atypical antipsychotic risperidone are offset by reductions in other mental health care utilisation and expenditure. Design and setting: The study was population-based and used South Carolina Medicaid claims data to determine changes in mental healthcare utilisation and expenditures related to schizophrenia. Changes in mental health-related utilisation and expenditures over time were calculated; total mental health-related expenditures and utilisation were disaggregated into pharmaceuticals, inpatient hospitalisations, and ambulatory and inpatient physician services [Health Care Financing Administration (HCFA) 1500 claims]. Groups of patients were compared for two 6-month periods preceding the initial prescription (pre1 and pre2), and two 6-month periods following the initial prescription (post1 and post2). Costs were discounted to the index date. Perspective: Payor (South Carolina Medicaid). Patients: Those patients with schizophrenia who received initial prescriptions for risperidone (n = 862), haloperidol (n = 325) or clozapine (n = 66) between February 1994 and June 1995 (index date). Main outcome measures and results: The mean increase in level of expenditure per person for pharmaceuticals from the pre- to the post-treatment period was significantly greater in the risperidone [751 US dollars ($US)] and clozapine ($US1423) groups than in the haloperidol group ($US6). However, the change in mean level of total mental healthcare expenditure per person was not significantly different for the risperidone group ($US832) compared with the haloperidol group ($US540) over the same time period, but the increase in the clozapine group was significantly higher ($US2500.23; p < 0.0001 for clozapine vs risperidone and clozapine vs haloperidol). As the difference between the risperidone and haloperidol groups in pharmaceutical expenditures was not reflected in total mental healthcare expenditures, the remaining component costs were investigated to identify where the difference was offset. Compared with haloperidol, risperidone had a significantly smaller change in per person mean level of ambulatory and inpatient physician services claims for expenditure ($US692 vs $US269, p = 0.01) and utilisation (+1.70 vs -0.21, p < 0.0001). Conclusions: Based on these findings, we conclude that, in this population of patients with schizophrenia increased costs associated with risperidone were offset by decreases in other mental healthcare utilization. Risperidone is a technical substitute for ambulatory healthcare services.
Disease Management and Health Outcomes 01/2001; 9(4):203-213. · 0.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This article examines evidence of the improved clinical, economic, and humanistic outcomes associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) in clinical practice, in particular in the areas of hypertension, diabetic nephropathies, post-myocardial infarction, and congestive heart failure. Pharmacodynamic and pharmacokinetic differences may exist among this class, however, these may not be clinically relevant when the drugs are given in equivalent doses. Although additional studies are necessary before a class effect can be assumed for each of these outcomes, it is important for clinicians to consider all of these outcomes when using ACEIs.
The American journal of managed care 03/2000; 6(3 Suppl):S112-28, quiz S129-31. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Structured diagnostic interviews indicate that the rate of depression among patients with diabetes mellitus (DM) is nearly 3 times that observed in the general population in the United States. Prevalence studies have reported a significant underdiagnosis of depression and a significant underutilization of antidepressant pharmacotherapy among patients with DM. The objective of this study was to determine the incidence of antidepressant utilization within the first year after diagnosis of type 1 (insulin-dependent) or type 2 (non-insulin-dependent) DM. This retrospective cohort study used adjudicated, patient-level, paid-claims data from the state of South Carolina's Medicaid program for the period January 1, 1990, through December 31, 1994. The study population comprised a statewide cohort of 3445 Medicaid beneficiaries diagnosed with type 1 or type 2 DM; aged 18 to 64 years; initiating pharmacotherapy with either insulin or a second-generation sulfonylurea (glipizide or glyburide); and without a prescription for antidepressant pharmacotherapy, insulin or an oral sulfonylurea (first- or second-generation) in the year before initiating a regimen to manage DM. Overall, 6.5% of patients (6.9% of patients with type 1 and 5.5% with type 2 DM) were prescribed antidepressant pharmacotherapy within the first year after beginning treatment with insulin or a second-generation sulfonylurea. Among patients with type 1 DM, 37.3% were prescribed a selective serotonin reuptake inhibitor compared with 50.9% of patients with type 2 DM. White patients were significantly more likely (P < 0.05) to have been prescribed antidepressant pharmacotherapy compared with black patients. Under the conservative assumption that the tricyclic antidepressants were prescribed only for complications arising from DM (eg, retinopathy and neuropathy) only 2.6% of patients with DM received antidepressant pharmacotherapy. Further research is required to discern the reasons for the low incidence of antidepressant utilization in patients with DM and for observed differences in prescription rates by race. In addition, initiatives are required to foster the development of educational programs designed to enhance the rate of screening for depression and receipt of pharmacotherapeutic and/or psychotherapeutic intervention among patients with DM.
Current Therapeutic Research 01/1999; 60(8):415-422. · 0.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: This paper reports results stemming from a retrospective inquiry designed to determine the prescribing pattern of tricyclic antidepressants (TCAs) relative to selective serotonin reuptake inhibitors (SSRIs), and the subsequent effect on regimen adherence among African American (Black) and White beneficiaries enrolled in the state of South Carolina Medicaid programme.Patients and Methods: Adjudicated patient-level paid-claims data for the time-frame 1 January 1990 to 31 December 1994 were abstracted resulting in a statewide cohort of 8596 ambulatory beneficiaries, 18 to 64 years of age, without receipt of antidepressant pharmacotherapy in the 1-year time-frame prior to initiating a regimen of either a TCA or SSRI, and remaining Medicaid-eligible for 1 year thereafter.Results: Black race [odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.43 to 1.70], age 40 to 64 years (OR = 1.15, 95% CI = 1.06 to 1.26), and male gender (OR = 1.27, 95% CI = 1.14 to 1.41) were significant predictors of initiating antidepressant pharmacotherapy with a TCA. Relative to Whites, Blacks were found to be less likely to have obtained at least a 3-month (90 days) supply of a TCA (22.1 vs 31.7%) or an SSRI (30.7 vs 36.1%), or to have obtained a 6-month (180 days) supply of a TCA (6.4 vs 10.9%) or an SSRI (8.1 vs 13.2%). Conclusion: Further prospective research is required to discern the reasons for observed differences in prescribing and adherence patterns for antidepressant pharmacotherapy by age, gender and race, and to foster the development of educational programming designed to ensure clinically rational and equitable access to pharmacotherapeutic innovation.
Clinical Drug Investigation 07/1998; 16(2):135-140. · 1.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors present a model that tests the economic value of a new diagnostic test that can identify type A and B influenza. Compared with traditional treatment without trying to objectively differentiate viral from bacterial infection, substantial cost savings may be achieved if diagnostic testing is appropriately utilized in a comprehensive influenza management program.
[Show abstract][Hide abstract] ABSTRACT: The results of a national survey of the ambulatory care functions of pharmacists in integrated health systems, including managed care organizations, are reported. Persons responsible for ambulatory care pharmaceutical services in 392 integrated health systems nationwide were interviewed by telephone and asked about their systems' organizational characteristics, information systems, pharmacist functions, and performance measures. Respondents reported a range of health-system components, including acute care hospitals, home health services, managed care products, and ambulatory care centers. Approximately 27% of respondents reported that their health system had an electronic medical records system, and 23% reported having one for ambulatory patients. Approximately 49% of respondents indicated that their system had an interdisciplinary care team for ambulatory patients that included a pharmacist. Overall, distributive functions consumed the largest portion (45%) of pharmacists' time, followed by clinical (30%) and administrative (21%) activities. The percentages of time spent on the different functions varied by geographic region and type of health system. Tracking adverse drug reactions, monitoring medication compliance, using pharmacoeconomic data for formulary decision-making, conducting medication management programs, and patient counseling were routinely provided as part of ambulatory care pharmaceutical services by 75% or more of health systems. Financial performance and patient satisfaction were the most frequently used performance-evaluation measures. Overall, pharmacists providing ambulatory care services in integrated health systems spent about 45% of their time on distributive, 30% on clinical, and 21% on administrative functions.
American Journal of Health-System Pharmacy 02/1998; 55(1):35-43. · 1.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The results of the 1996 ASHP national survey of pharmaceutical services in nonfederal community hospitals are presented and compared with the findings of the 1994 ASHP survey. A questionnaire was mailed to pharmacy directors at hospitals randomly sampled from those registered by the American Hospital Association. A total of 713 usable surveys were returned, for a net response rate of 37.1%. Inpatient pharmaceutical services were provided an average of 17.4 hours per weekday and ambulatory care pharmaceutical services 13.3 hours per weekday. Pharmacy directors were more likely to have duties beyond the department than in 1994 (24% versus 12%). The percentage reporting a patient-focused-care model increased from 18% in 1994 to 33% in 1996. The percentage reporting some automation of drug distribution increased from 55% in 1994 to 65% in 1996. Provision of ambulatory care pharmaceutical services was indicated by 63% of respondents, and 35% indicated providing home infusion services. Compared with 1994, pharmacy departments provided more clinical services to inpatients. The most commonly offered clinical pharmacy services for inpatients were drug-food interaction screening, drug-use evaluations, adverse-drug-reaction programs, and medication error management programs. The percentage providing pharmaceutical care to some extent increased from 44% to 60%. The percentage reporting that pharmacists had the authority to initiate or modify medication orders increased from 35% to 56%. A well-controlled formulary system was in place at 60% of hospitals, while 39% reported restrictions on prescribing. Nearly three fourths of respondents reported a therapeutic interchange policy. Mean inventory cost per patient day was $4.67, a decrease from $5.62 in 1994. About 68% of inpatient pharmacy expenditures went for drugs and fluids, 27% for staff, and 5% for other noncapital expenditures. The 1996 ASHP survey revealed continued growth in various activities related to patient care, such as implementation of patient-focused care, enhanced clinical services, and therapy management programs. Although the provision of pharmaceutical care increased, ample room for growth remains.
American Journal of Health-System Pharmacy 04/1997; 54(6):653-69. · 1.98 Impact Factor