The National Oncology Working Group (NOW) initiative: payer and provider collaborations in oncology benefits management.

Payers recognize the need to expand benefits management for oncology but struggle to find effective solutions amid the complexity of available therapies and skepticism from oncologists, who are facing their own set of economic pressures. An effort called the National Oncology Working Group (NOW) Initiative is trying to change the sometimes adversarial relationship between payers and oncologists through a collaborative model. The group, which is supported by pharmaceutical manufacturer sanofi-aventis, is developing patient-centered strategies for successful and sustainable oncology benefits management. The focus includes finding consensus between payers and providers and devising solutions for oncology management such as decreasing variability of cancer care and improving end-of-life care for patients with terminal illness. NOW is designing tools that will be tested in small-scale regional demonstration projects, which NOW participants anticipate will set an example for successful oncology benefits management that can be replicated and expanded.

Drug and medical cost effects of a drug formulary change with therapeutic interchange for statin drugs in a multistate managed Medicaid organization.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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.

Leadership versus management: translating pharmacists' abilities into quality performance.

OBJECTIVE: 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. SUMMARY: 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. CONCLUSION: 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."

A comparison of the cost-effectiveness of almotriptan and sumatriptan in the treatment of acute migraine using a composite efficacy/tolerability end point.

OBJECTIVE: To use a composite efficacy/tolerability end point to compare the cost-effectiveness, from the perspective of a U.S. health care payer, of almotriptan and sumatriptan in the treatment of an acute migraine attack. METHODS: The composite end point. Sustained pain free and No Adverse Events. (SNAE) was created from the sustained pain free and adverse event rates obtained in a meta-analysis of 53 placebo-controlled trials of oral triptans. The total direct cost of treating a single migraine attack was calculated from published sources. RESULTS: In the base-case analysis, the average cost-effectiveness ratios (CERs) were 82 US dollars , 133 US dollars , and 138 US dollars (per attack at which SNAE is achieved, 2004 prices) for almotriptan 12.5 mg, sumatriptan 50 mg, and sumatriptan 100 mg, respectively; the incremental CERs for almotriptan 12.5 mg were 12 US dollars and 16 US dollars (compared with sumatriptan 50 mg and sumatriptan 100 mg, respectively) per incremental attack at which SNAE is achieved. Sensitivity analyses were conducted to explore the impact of (1) relaxing the base-case assumptions (independence of efficacy and tolerability, uniform apportionment of health service use costs across attacks, number of tablets used to treat 1 attack); (2) varying input costs; and (3) uncertainty in the efficacy and tolerability estimates from the meta-analysis. In all of these sensitivity analyses, almotriptan 12.5 mg remained cost effective compared with sumatriptan 50 mg and 100 mg. CONCLUSION: Almotriptan was economically superior to sumatriptan in the treatment of a migraine attack.

Effects of an increase in prescription copayment on utilization of low-sedating antihistamines and nasal steroids.

BACKGROUND: Health plans are using 3-tier copayment designs and other methods to control utilization that shifts drug costs to plan members. There is a need to determine the effects of increased member cost sharing on drug utilization and drug costs. OBJECTIVE: To assess the impact of a 10 US dollars increase in prescription copayment in a public employer health plan for 2 classes of drugs used for allergic rhinitis. METHODS: Changes in the number of prescriptions dispensed for 2 therapeutic classes.low-sedating antihistamines (LSAs) and nasal steroids (NSs).were examined 1 year prior to and 1 year after copayment increase. Relative price effects were measured as arc price elasticity, the ratio of the percent change in prescription utilization over the percent change in price, an indicator of how responsive patients are to the copayment increase. RESULTS: Of 8,643 continuously enrolled health plan beneficiaries, 2,150 patients (24.8%) received at least 1 NS or LSA during the 2-year period of the study, from January 1, 1998, through December 31, 1999. An average 10 US dollars increase in copayment per prescription was associated with no statistically significant change in utilization of combined LSA and NS prescriptions, 2.89 per patient in 1998 and 2.94 in 1999 (P = 0.597). Health plan costs for study drugs, unadjusted for inflation, decreased by 16.3% from 86.86 US dollars per patient in 1998 to 72.68 US dollars in 1999 (P = 0.004). Health plan costs per patient per month (PPPM) for all drugs for the 2,150 allergic rhinitis patients decreased by 13% from 41.33 US dollars PPPM in 1998 to 35.93 US dollars in 1999 (P<0.001), and health plan drug costs for all 8,643 members decreased by 13% from 14.93 US dollars per member per month (PMPM) in 1998 to 12.99 US dollars in 1999 (P<0.001). The actual average copayment increase was 7.23 US dollars (a 41% increase) for LSAs, which was associated with a 14.8% increase in utilization of LSAs and an 11.8% increase in the number of patients using LSAs; the number of LSA prescriptions per patient per year was unchanged at 2.68 in 1999 versus 2.61 in 1998 (P = 0.429). The actual average copayment increase was 10.98 US dollars (71%) for NSs, which was associated with an 11.3% decrease in utilization of NSs and a 10.2% decrease in the number of users of nasals steroids in 1999; the number of nasal steroid prescriptions per patient per year was unchanged at 2.05 in 1999 versus 2.07 in 1998 (P =.842). The combined utilization of LSA and NS prescriptions increased by 8.9% following the increase in copayments for these 2 therapeutically interchangeable drugs for allergic rhinitis. LSA prescriptions were less elastic, with an unadjusted arc elasticity of 0.39, while nasal steroid prescriptions were more responsive to the copayment change, with an unadjusted arc elasticity of.0.22. CONCLUSIONS: An average 10 US dollars increase in patient cost sharing per prescription (46.9% copayment increase) was associated with an increase in combined utilization of 2 drug classes used for allergic rhinitis (LSAs and NSs) but no change in the number of prescriptions per patient. Health plan costs decreased significantly for allergic rhinitis drugs, all drugs used by allergic rhinitis patients, and all drugs used by continuously enrolled health plan members. NSs exhibited a greater arc price elasticity compared with low-sedating oral antihistamines.

Cost-effectiveness of almotriptan and rizatriptan in the treatment of acute migraine.

BACKGROUND: 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. OBJECTIVE: The aim of this study was to assess the relative cost-effectiveness of almotriptan and rizatriptan in the treatment of acute migraine. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

A comparison of office-based physician visits for irritable bowel syndrome and for migraine and asthma.

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.

Economic comparison of oral triptans for management of acute migraine: implications for managed care.

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 impact of angiotensin-converting enzyme inhibitors on managed care: economic, clinical, and humanistic outcomes.

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.

An economic model for a novel viral influenza diagnostic.

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.

ASHP survey of ambulatory care responsibilities of pharmacists in integrated health systems--1997.

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.

Antidepressant prescribing patterns: a comparison of blacks and whites in a medicaid population.

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.

ASHP national survey of pharmacy practice in acute care settings--1996.

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.

Overview of pharmacoeconomics and pharmaceutical outcomes evaluations.

The principles, methods, and applications of pharmacoeconomics and pharmaceutical outcomes evaluations are discussed. Pharmacoeconomics may be defined as balancing the cost with the consequences (outcomes) of pharmaceutical therapies and services. As a type of outcomes evaluation, pharmacoeconomics looks beyond just the direct or acquisition cost of a pharmaceutical by including its impact on total health resource utilization and costs. Outcomes research attempts to answer the question, What difference does the pharmaceutical make in patient outcomes under real-world conditions? The economic, clinical, and humanistic outcomes (ECHO) model for a pharmacoeconomic evaluation views the drug as some combination of its clinical, economic, and humanistic attributes. Safety and effectiveness are no longer the only salient attributes of a drug; the effect on total health resource utilization, cost, and quality of life must also be evaluated. The four types of pharmacoeconomic methods are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. As disease state management continues to emerge as a cost-management, quality assurance strategy, formularies per se will wane in importance and pharmacoeconomic and outcomes data will increase in relevance as health professionals endeavor to find the most efficient and effective combinations of medical care. Pharmacoeconomics as a component of outcomes research will help pharmacists decide which clinical circumstances, patient characteristics, and practice settings are most suitable for particular interventions.

A literature review comparing the economic, clinical, and humanistic attributes of dihydroergotamine and sumatriptan.

The value of different pharmaceuticals in treating migraine is frequently based on clinical efficacy only. This article assumes a broader perspective and compares the clinical, economic, and humanistic attributes of two antimigraine medications, dihydroergotamine (DHE) and sumatriptan, based on a literature review. DHE is an established product with over 40 years of use in the treatment of migraine. Sumatriptan is a new product with a higher acquisition cost than DHE. Because sumatriptan costs more than DHE, the question must be asked. "Does sumatriptan provide advantages that offset this price differential?" This question reflects the growing concern among payers and patients over the cost and effectiveness of therapies. However, it is not easily answered. Direct comparative data are not available, and data sources are different for the two products. Moreover, the products are currently marketed in different dosage forms--intramuscular for DHE and subcutaneous for sumatriptan. The literature reviewed indicates that the clinical attributes of the two products are similar, with each having slightly different advantages and disadvantages. However, the DHE literature is generally limited to uncontrolled studies, whereas the sumatriptan literature reports the results of rigorously designed, randomized, double-blind, placebo-controlled clinical trials. Published data on the products' economic and humanistic attributes are limited. We concluded that the literature does provide important, albeit limited, data on the economic, clinical, and humanistic attributes of DHE and sumatriptan that permit restricted comparisons. The limitations of the data highlight the need for comparative studies of these products' multidimensional attributes both in controlled clinical trials and under actual practice conditions.