Reducing drug costs at a Veterans Affairs hospital by increasing market-share of generic fluoxetine.

We previously showed that a multifaceted intervention designed to contain costs of prescribing selective serotonin reuptake inhibitors (SSRIs) at a Veterans Affairs hospital resulted in substantial projected savings. Intervention components included clinician education and pharmacy and computer information process changes. We now report on effects of altering the intervention to promote prescribing of generic fluoxetine. Over 30 months, fluoxetine's market-share increased from 12 to 32% of all SSRIs prescribed. A total of $2,500,000 in cost avoidance resulted from substituting generic for brand fluoxetine, and $600,000 resulted from increases in market-share of fluoxetine. The results highlight the robustness and flexibility of the intervention approach.

Impact of a clinical pharmacy consult service on guideline adherence and management of gabapentin for neuropathic pain.

OBJECTIVE: Our objectives were to (1) determine whether a computerized clinical pharmacy approval and follow-up consult process for ordering new prescriptions for gabapentin for the treatment of neuropathic pain decreased the number of patients without documented treatment benefit while increasing follow-up and documentation of effectiveness, and (2) describe gabapentin use patterns at a Veterans Affairs (VA) Medical Center, including the use of first-line therapies prior to gabapentin therapy for neuropathic pain. METHODS: The clinical pharmacy intervention included review of (1) the indication for gabapentin; (2) the required use and failure or contraindication of 3 first-line therapies: nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants (TCAs), and capsaicin cream; (3) the initial pain assessment; and (4) patient follow-up in 4 to 6 weeks, with repeat pain assessment. A retrospective chart review was performed for all patients who received a new prescription for gabapentin from October 2002 to April 2003 at the Portland VA Medical Center (PVAMC). The outcomes of interest for the provider group versus the clinical pharmacy managed group included follow-up at 6 weeks or less versus follow-up at more than 6 weeks, documentation of treatment benefit, how many of the 3 first-line therapies were tried before gabapentin, and whether the gabapentin therapy was discontinued. RESULTS: There were 237 patients who received a new prescription for gabapentin between October 2002 and April 2003. Of these gabapentin prescriptions, 61% (n=144) were prescribed for neuropathic pain. Of the new gabapentin prescriptions for neuropathic pain, 61% (n=88) were made from approved clinical pharmacy consults, 38% (n=54) were ordered without a clinical pharmacy consult, and 1% (n=2) were not included because the patient received the drug despite denial by the clinical pharmacy consult. The rate of follow-up to assess documentation of benefit of therapy with gabapentin was 87% (n=62) in the clinical pharmacy consult group compared with 51% (n=27) in the provider-managed group (chi2=18.07, P<0.001). Of the patients who were assessed by follow-up, 89% (n=55) of the clinical pharmacy consult group received follow-up within 6 weeks versus 52% (n=14) of the provider-managed group (chi2=12.63, P <0.001). Compared with the patients managed by clinical pharmacists, 43% (n=23) of the gabapentin patients in the provider-managed group had no evidence of prior use of any of the 3 agents required by the gabapentin neuropathic pain guideline, 55% (n=29) had evidence of prior use of 1 or 2 first-line agents, and only 2% (n=1) had evidence of prior use of all 3 required first-line agents, versus 100% (n=71) of the patients managed by clinical pharmacy consult. There was no difference in the rate of continuation of gabapentin therapy in the group of patients who received clinical pharmacy consults (65%) compared with the provider-managed group (68%, chi2=0.11, P=0.718). Of the 148 pharmacy consults for new gabapentin prescriptions that were completed during the 7-month period from October 2002 through April 2003, 60 (40%) were denied, which resulted in the lack of gabapentin use in these 60 patients. CONCLUSIONS: A clinical pharmacy intervention as part of the management of a treatment guideline for appropriate gabapentin use promotes documentation of drug therapy effectiveness in neuropathic pain and prevention of gabapentin use prior to a trial with alternative first-line therapies.

Strategies to decrease costs of prescribing selective serotonin reuptake inhibitors at a VA Medical Center.

OBJECTIVE: The authors examined the efficacy of a multifaceted intervention designed to contain the cost of prescribing selective serotonin reuptake inhibitors (SSRIs) to inpatients and outpatients served by a Veterans Affairs (VA) medical center. METHODS: Elements of the intervention included identification of a preferred agent, tablet splitting, education and feedback for prescribers, and an electronic record and ordering system to facilitate changes in prescriber behaviors. VA databases were searched for information on use and costs of antidepressants. RESULTS: Over 35 months the number of patients treated with SSRIs and the amount spent on SSRIs increased. However, the mean monthly cost per patient decreased from $57.12 to $42.19. The projected cost savings over the 35 months was approximately $700,000; one-fourth of the savings was due to tablet splitting and three-fourths to changes in the proportions of the various SSRIs prescribed. A survey of the top 75 antidepressant prescribers showed that after the educational interventions, 91 percent were aware that citalopram was the medical center's preferred antidepressant, and 59 percent identified it as their own preferred first-line treatment. DISCUSSION AND CONCLUSIONS: The results suggest that multifaceted interventions can influence antidepressant costs through provider education and changes in pharmacy and computerized information processes, resulting in substantial cost savings for institutions.