The importance and impact of evidence-based medicine.

OBJECTIVE: To describe the new paradigm of evidence-based medicine (EBM) and the benefits of using EBM in making treatment decisions for individual patients. SUMMARY: Applying the knowledge gained from large clinical trials to patient care promotes consistency of treatment and optimal outcomes, helps establish national standards of patient care, and sets criteria to measure and reward performance-based medical practice. Implementing the principles of EBM, which rely on the rules of evidence and research, requires a commitment from medical schools, local health and medical licensing departments, physicians, pharmacists, professional associations, and managed care organizations. A review of results from landmark trials in hypertension, diabetic nephropathy, and end-stage renal disease describes the research for evidence-based therapies. A review of studies in the pharmacist.s expanding role in implementing evidence-based medicine shows the benefits of collaborative medical practices. CONCLUSION: Implementation of EBM in the managed care setting provides standards that have the potential to provide the best medical care at the lowest cost.

Effects of a 3-tier pharmacy benefit design on the prescription purchasing behavior of individuals with chronic disease.

OBJECTIVE: To evaluate the impact of 3-tier (copayment) pharmacy benefit structures on medication utilization behavior. METHODS: A pretest-posttest quasi-experimental design was employed. Chronic disease sufferers (N=8,132) from a health plan were classified into the following groups: (a) 2-tier copayment moving to a 3-tier structure, (.converting. group), (b) 2-tier staying in a 2-tier structure and, (c) 3-tier staying in a 3-tier structure. The latter 2 were.comparison. groups. Two 7-month time periods were determined: the.preperiod. (June through December 2000) and the.postperiod. (January through July 2001) for a change in pharmacy benefit structure. Pharmacy claims data were used for data collection. Statistical analyses included bivariate tests to evaluate predifferences and postdifferences across study groups. Maximum likelihood estimates from a repeated measures model were used to examine changes in formulary compliance and generic use rates. Discontinuation of nonformulary medications was evaluated using logistic regression. RESULTS: Controlling for demographics, number of comorbidities, disease state, and pharmacy benefit structure, the formulary compliance rate increased by 5.6% for the converting group. No significant increases were seen for the comparison groups. Generic use rates increased by 6 to 8 absolute percentage points for all groups (3.3% to 4.9 % adjusted rates). Converting group members were 1.76 times more likely to discontinue their nonformulary medication than those in the 2-tier comparison group and 1.49 times more likely than those in the 3-tier comparison group. CONCLUSIONS: These findings suggest that shifting individuals from a 2-tier to a 3-tier drug benefit copayment structure resulted in changes in medication utilization. Decision makers need to balance these changes with the potential dissatisfaction that members may express in paying higher copayments.