Pharmacy Expenditures Research Articles

Association between hospital size and pharmacy department productivity

The purposes of this study were to characterize and quantify workload and productivity in hospitals according to their size, to establish comparative statistics useful for pharmacy administrators as a means to contrast their efficiency to that of other hospitals of similar sizes, and to provide data to enable policymakers to better assess staffing and resource needs. A 50-item Web-based survey designed to illicit information about pharmacy department staffing, workload, and productivity was sent electronically to 242 members of Consorta, Inc., a group-purchasing organization. Responses were received from 110 organizations, a response rate of 45.5%. The responses were categorized into three groups according to the number of staffed beds and were profiled and compared using descriptive and inferential statistics. Pharmacy department workload and expenditures were primarily a function of hospital size: Hospital volume statistics, pharmacy expenditures, hours of operation, pharmacy full-time equivalents (FTEs), and dispensing workload all are highly dependent on the size of the facility. The range of clinical services provided by small, medium, and large hospitals did not differ with the exception of a few services provided more often in larger hospitals. Overall productivity ratios demonstrated greater efficiency among larger hospitals. In terms of costs, pharmacy and hospital expenditures per occupied bed and per admission generally decreased as hospital size increased. Results of a survey suggested consistency in clinical services provided by hospitals of varying size and increased productivity with increasing hospital size. Respondents employed fewer FTEs than those in other national surveys.

Effect of oseltamivir on the risk of pneumonia and use of health care services in children with clinically diagnosed influenza

ABSTRACTObjective: To evaluate the effectiveness of oseltamivir in reducing the rate of complications of influenza in children.Research design and methods: Anonymous, patient-level data from Medstat's MarketScan Research Database between 2000 and 2004 were used to identify children with influenza, aged 1–12 years. Patients who received a prescription for oseltamivir within 1 day of influenza diagnosis were compared with those who received no antiviral therapy.Main outcome measures: Primary and secondary study outcomes included occurrence of pneumonia within 14 days of onset of influenza, rates of hospitalization for pneumonia, antibiotic use, numbers of healthcare services utilized, and healthcare expenditures.Results: In total, 4447 (17.9%) children received a prescription for oseltamivir within 1 day of when they were first clinically diagnosed with influenza, and 20 407 (82.1%) children received no antiviral treatment. Overall, children who received oseltamivir for the treatment of physician-diagnosed influenza were 51.7% less likely to be clinically diagnosed with pneumonia at a subsequent medical encounter (relative risk 0.483; 95% CI: 0.326, 0.717). This benefit was associated with reductions in antibiotic use, outpatient and emergency room visits, and savings in outpatient medical expenditures. Net expenditures per patient were not significantly different between children receiving oseltamivir and those who received no antiviral treatment (–$16; 95% CI: –$13, +$40) although pharmacy expenditures were higher. Wide regional variations in oseltamivir use were noted.Limitations: The study was restricted to patients with employer-sponsored health insurance. The lack of a virologic diagnosis of influenza, and an index date based on the first diagnosis of influenza rather than first exposure or symptom onset, may have resulted in a conservative estimate of treatment effect.Conclusions: Oseltamivir may reduce the risk of influenza-related morbidity in children when prescribed upon presentation of clinically diagnosed influenza. The use of oseltamivir in children may play an important role in managing influenza outbreaks.

Bayesian Inference for a Two-Part Hierarchical Model

Profiling is currently an important, and hotly debated, topic in health care and other industries looking for ways to control costs, increase profitability, and increase service quality. Managed care in particular has seen a proliferation in the use of statistical profiling methodology, particularly with regard to monitoring expenditure data. This article focuses on the specific problem of developing statistical methods appropriate for profiling physician contributions to patient pharmacy expenditures incurred in a managed care setting. The two-part hierarchical model with a correlated random-effects structure considered here accounts for both the skewed, zero-inflated nature of pharmacy expenditure data and the fact that patient pharmacy expenditures are correlated within physicians. The random-effects structure has an attractive interpretation in terms of a conceptual model for physician prescribing patterns. Using this model, we propose to rank physicians based on an appropriately constructed provider-level performance measure. This information is subsequently used to develop a novel financial incentive scheme. Inference is conducted in a Bayesian framework using Markov chain Monte Carlo.

Assessment of clinical, service, and cost outcomes of a conversion program of sumatriptan to rizatriptan ODT in primary care patients with migraine headaches.

Managed care organizations can increase the value of drug therapy by negotiating discounts on drug acquisition costs with pharmaceutical manufacturers and promoting use of preferred drugs, including the conversion of patients to preferred medications. This investigation was designed to assess conversion success, migraine drug utilizations, and patient satisfaction with a clinical pharmacist-managed conversion program from sumatriptan to rizatriptan ODT, both formulary drugs. This was a retrospective cohort study conducted in a managed care organization for patients aged 18 years or older who had picked up at least one outpatient prescription for any sumatriptan dosage form at the pharmacy between January 2002 and June 2002. Patients. pharmacy and medical data were reviewed to assess eligibility (e.g., no history of rizatriptan failure) for conversion from sumatriptan to rizatriptan orally disintegrating tablet (ODT). There was no copayment difference for members for rizatriptan ODT versus sumatriptan. A questionnaire was developed to assess 2 domains: (1) patient satisfaction with the medication conversion process and (2) preference for rizatriptan ODT or sumatriptan. A random sample of 315 patients who initiated conversion to rizatriptan ODT was surveyed. Electronic pharmacy claims were reviewed to determine the number of patients who were successfully converted from sumatriptan to rizatriptan ODT. Pharmacy expenditures and total health care utilization and expenditures in the 180 days prior to (baseline) and after the conversion (followup) to rizatriptan ODT were compared for the cohorts of subjects who were successfully converted and those patients who were not successfully converted. Therapeutic conversion from sumatriptan to rizatriptan ODT was attempted in 457 patients; 214 (47%) were successfully converted. The only difference between the 2 cohorts at baseline for the 6 months prior to attempted conversion was a higher mean number of sumatriptan doses per patient per month (PPPM) in the 243 failed conversions (mean 3.5, SD 2.9) compared with the 214 successful conversions (mean 2.8, SD 2.8, P =0.003). The median triptan doses increased by 1.0 PPPM in both cohorts (P =0.882), from 2.0 to 3.0 doses PPPM in the group of successful conversions and from 2.7 to 4.0 in the group of unsuccessful conversions. The survey response rate was 55% for both successful and for unsuccessful conversions. More than 90% of the patients in both cohorts were satisfied with the level of care provided by the clinical pharmacy staff during medication conversion, and there was no difference between the 2 cohorts in patient satisfaction (P=0.761). Rizatriptan ODT was preferred by 68.0% and 8.5% of successful and failed conversion subjects, respectively (P <0.001). Using representative group purchase prices, triptan expenditures for successful conversion subjects were reduced by a median of -2 dollars (6 %) PPPM while triptan expenditures for unsuccessful conversions increased by a median of 8 dollars (P <0.001). There were no differences for either cohort in median PPPM changes in migraine-related office visits (0.0 median change in office visits, P =0.748) or office-visit costs (0 dollars median change, P =0.861) for preconversion versus postconversion attempts Regression modeling identified that lower total counts of sumatriptan doses filled during baseline period was an independent predictor of successful conversion to rizatriptan ODT (P <0.001). There was an average of 3.5 triptan medication fills per patient for successful conversion during the 6-month follow-up period, with 78% of these subjects filling at least 2 prescriptions for rizatriptan ODT during this period. This conversion program for sumatriptan to rizatriptan ODT was successful in converting almost half of primary care patients to the preferred product despite the absence of a copayment incentive for members to agree to the conversion. There were no measurable medical or economic consequences of the conversion, and patient satisfaction with the quality of care was maintained. Future efforts are likely to have a higher success rate if focused on converting patients with less-severe migraine headaches, as measured by the need for baseline rescue medication, since lower acuity was the only independent predictor of successful conversion in this conversion program for 2 triptan drugs.

Medical and Pharmacy Expenditures After Implementation of a Cyclooxygenase-2 Inhibitor Prior Authorization Program

To evaluate the effects of a cyclooxygenase (COX)-2 inhibitor prior authorization (PA) program on direct medical and pharmacy costs. Prospective, pre- and postimplementation cohort study with reference group. Large corporation in the Midwest. Of 26,375 continuously enrolled members, 737 used a COX-2 inhibitor in the 3 months before January 1, 2003, when the PA program was implemented. The PA program limits coverage for a COX-2 inhibitor to members with a documented risk for a nonselective nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal adverse event. All pharmacy and medical claims and costs were analyzed from the payer's perspective for a 15-month period. Separate pharmacy cost comparisons and medical cost comparisons were made between the 3-month quarter before PA program implementation and each follow-up quarter after PA program implementation. In the 3 months after PA program implementation, 620 (84.1%) of 737 members had no claims for a COX-2 inhibitor, and during this period their pharmacy and medical costs initially declined 40.0% (p < 0.001) and 18.7% (p < 0.001), respectively, and remained significantly lower. Among a subgroup of 156 members who tried to fill a COX-2 inhibitor prescription but were denied coverage, pharmacy and medical costs initially declined, 48.1% (p < 0.001) and 10.3% (p < 0.001), respectively, with pharmacy costs remaining significantly lower; however, overall medical expenditures increased, then returned to baseline. No change was noted in physician outpatient encounters, and two members had an emergency department visit for abdominal pain with no gastrointestinal ulcerations or bleeds during the 12-month follow-up. Among members denied coverage for a COX-2 inhibitor after implementation of a PA program, pharmacy costs declined without a medical cost increase associated with gastrointestinal diagnoses.

Results of an antimicrobial control program at a university hospital

The results of the first five years of an ongoing antimicrobial control program are reported. In 1998, a multidisciplinary antimicrobial subcommittee of the pharmacy and therapeutics committee of a university hospital was formed and charged with making formulary interventions in an effort to reduce rising antimicrobial resistance rates and drug expenditures. In 1999, a number of measures were implemented for controlling antimicrobial use. Selected antimicrobials with the potential for inappropriate use or whose inappropriate use had been documented were placed in the control of physicians in the infectious diseases (ID) division. Prior approval by an ID physician was required before the pharmacy could dispense these agents. Other key interventions included removal of ceftazidime and cefotaxime from the formulary, restriction of vancomycin and carbapenem use, and replacement of ciprofloxacin with levofloxacin as the sole fluoroquinolone on the formulary. Data regarding antimicrobial use and expenditures between 1998 and 2002 were compared and analyzed. Antimicrobial use was reduced by 80% for third-generation cephalosporins and 15% for vancomycin following the implementation of the new antimicrobial policies. Antimicrobial-resistance patterns for many important gram-negative pathogens, including Pseudomonas aeruginosa, demonstrated a reversal of previous increases. In addition, the rate of methicillin-resistant Staphylococcus aureus decreased by an average of 3% each year from 1999 to 2002. Pharmacy expenditures for all antimicrobials, including antiviral, antifungal, and antibacterial agents, decreased 24.7%, with a cumulative cost saving of 1,401,126 US dollars, without inflation assumptions. The implementation of an antimicrobial control program decreased the use of selected antimicrobial agents and resulted in substantial reduction of expenditures for antimicrobials.

Restricting patients' medication supply to one month: saving or wasting money?

A state Medicaid program's pharmacy expenditures associated with dispensing one- and three-month supplies of drugs were examined. We simulated the effect of a policy change from a maximum of a 100-day supply of prescription medication to one where only a 34-day supply was allowed. All North Carolina prescription claims from Medicaid enrollees who filled a prescription for at least one of six medication categories during fiscal years 1999 and 2000 were included. The six categories were angiotensin-converting-enzyme inhibitors, antiulcers, antipsychotics, nonsteroidal antiinflammatory drugs, selective serotonin-reuptake inhibitors, and sulfonylureas. The dollar value of the medication wasted, the amount of medication wastage diverted after a change to a shorter prescription length, and the total costs incurred by the increases in prescription refills were calculated. For each therapeutic category, 255,000-783,000 prescription drug claims were analyzed. No valid drug claims were excluded for any reason. Although 5-14% of total drug wastage, attributed to switches of drug therapy, could be saved by dispensing a 34-day supply, this saving could not make up for a larger increase in dispensing costs, as consumers would fill prescriptions more often. In addition, reducing the amount of drug dispensed each time may be costly to consumers through increased transportation and other expenses. Simulated calculation showed that the cost of drug therapy to North Carolina's Medicaid program would probably increase if 34-day rather than 100-day supplies of medications are dispensed to patients.

Polypharmacy: Too Much Of a Good Thing?

Polypharmacy: Too Much Of a Good Thing?

Pharmacy Costs and Glycemic Control in the Department of Veterans Affairs

To determine pharmacy costs for glycemic treatment and its relationship to glycemic control in the Department of Veterans Affairs (VA) between 1994 and 2000. Patients with diabetes in the VA in FY1994, FY1996, FY1998, and FY2000 were identified using an ambulatory care pharmacy-derived database. Total drug acquisition costs, as well as expenditures for insulin, oral glycemic control agents, and self-blood glucose monitoring strips, were determined for these veterans. HbA(1c) levels for the corresponding time periods were also obtained. Pharmacy costs (medications and monitoring) were examined by glycemic control treatment type. In FY2000, 18% (n = 535,016) of all VA pharmacy patients were identified as having diabetes, and they received 30% of all pharmacy prescriptions. Overall, 23% of pharmacy expenditures for these patients were related to glycemic control medications and monitoring supplies. Annual pharmacy costs increased from FY1994 to FY2000. The greatest change was the higher expenditure for monitoring supplies through FY1998, which then decreased in FY2000. Increased pharmacy costs were associated with improved glycemic control. In FY2000, the mean last HbA(1c) level (n = 446,384) fell to 7.6% from 7.8% in FY1998 (n = 204,136) and 8.4% in 1996 (n = 53,348). Diabetes was associated with high pharmacy costs. Increasing medication expenditures were associated with improved HbA(1c) levels at the aggregated national level. Policies concerning dispensing monitoring supplies and several diabetes quality improvement projects were initiated during this interval. Future challenges include initiatives to further optimize care while controlling costs.

National estimates of health services expenditures for children with behavioral disorders: an analysis of the medical expenditure panel survey.

Children with attention-deficit/hyperactivity disorder and asthma incur similar health care costs that are greater than those of most children without these conditions. Preliminary findings suggest that children with emotional behavioral disorders, anxiety and depression, incur even greater costs. To determine if children with behavioral disorders have similar health services expenditures as children with physical conditions and to assess whether children with emotional behavioral disorders incur greater expenditures than children with disruptive behavioral disorders. Children 2 to 18 years old who were members of households participating in the 1996 Medical Expenditure Panel Survey were eligible for this retrospective cohort study. Children with common behavioral disorders selected a priori were identified by using truncated International Classification of Diseases (Ninth Revision) codes obtained from household interviews. Children with common physical conditions (asthma, epilepsy, and diabetes) and children without these conditions served as controls. Estimates were weighted to reflect the complex sampling scheme. Expenditures for health services were compared. Of 3955 eligible children weighted to represent >44 million, 7.1% were identified with a behavioral disorder: 4.5% with disruptive disorders; 2.1% with emotional disorders; and 0.5% with miscellaneous disorders. Children with behavioral disorders incurred overall expenditures similar to children with physical conditions (adjusted 1492 dollars vs 1245 dollars; P =.18) but greater than children without these conditions (adjusted 1492 dollars vs 834 dollars; P =.001). Children with behavioral disorders had greater expenditures for office-based visits (adjusted 410 dollars; 95% confidence interval: 146-672 dollars) and prescription medications (adjusted 361 dollars; 95% confidence interval: 72-648 dollars) than those of children in either control group. Among children with behavioral disorders, children with emotional disorders incurred substantially greater overall expenditures (adjusted 2152 dollars vs 1026 dollars; P =.003) than children with disruptive disorders. Children with emotional disorders incurred greater hospitalization expenditures (664 dollars vs 43 dollars; P =.01) but lower pharmacy expenditures (154 dollars vs 307 dollars; P =.001) than children with disruptive disorders. In this nationally representative sample, children with behavioral disorders incurred overall health care costs similar to children with physical conditions but greater than children without any of these conditions because of increased costs for office-based visits and prescription medications. However, costs were not uniform among children with behavioral disorders. Children with emotional disorders incurred twofold higher costs than children with disruptive disorders. Greater recognition of children with emotional disorders and efforts to address the high rate of hospitalizations in this population are warranted.

Impact of Disease Management on Cost-Effectiveness of Medicare Spending

Findings from the third annual Tufts Center for the Study of Drug Development survey of 22 leading disease and pharmacy benefits managers suggest that incorporation of disease management into Medicare would lower hospital inpatient costs. However, it is unclear whether hospital cost savings would be sufficient to offset increases in pharmacy, physician, and outpatient expenditures as a result of an added combination disease management and pharmacy benefit. Furthermore, the survey indicates that the Centers for Medicare & Medicaid Services (CMS) would likely struggle in recruiting disease managers due to their limited enrollment of Medicare beneficiaries, relative inexperience with contracts that put disease managers at risk, and only sporadic use of randomized design studies to test and prove the efficacy of disease management interventions. Thirteen of the 22 survey respondents are currently considered early compilers per accreditation standards developed by the National Committee on Quality Assurance. However, none of the 22 survey respondents compty with the stringent CMS requirements described in the solicitation for the 2002 disease management demonstration.

Managed care: improving psychiatric drug benefit management: I. Lessons from Massachusetts.

Managed care: improving psychiatric drug benefit management: I. Lessons from Massachusetts.

DB Partners With State To Develop Drug Formulary

Back to table of contents Previous article Next article Government NewsFull AccessDB Partners With State To Develop Drug FormularyKate MulliganKate MulliganSearch for more papers by this authorPublished Online:16 May 2003https://doi.org/10.1176/pn.38.10.0012Representatives of the Massachusetts Psychiatric Society (MPS) and state officials approached the divisive task of cutting the Medicaid budget with a spirit of good will and a commitment to patient needs.The most recent payoff is the decision by the state’s Division of Medical Assistance and Department of Mental Health to accept principles for drug formularies developed by MPS (Original article: see box).MPS President Elizabeth Childs, M.D., told Psychiatric News, “In light of the state’s budget crisis, it seemed naïve and counterproductive to take a position that psychotropic drugs should be unaffected by the establishment of a preferred drug list [PDL].”Instead, she said, members are directing their energy to the challenge of designing the “fairest, most clinically conscientious, evidence-based list possible.”In a letter to MPS members, President-elect James M. Ellison, M.D., one of four MPS representatives on the state’s Psychopharmacology Work Group, described other indications of progress that resulted from involvement with the work group.They include delay of implementation of the PDL until further consideration is given to addressing potential hazards, significant widening of the options for drug choice, considerable simplification of the prior-authorization and appeal processes, and acceptance of the notion that a psychiatrist must be involved in reviewing rejected requests.As members of the work group, Ellison and other MPS members also helped develop an educational effort to change prescribing patterns that are costly, but whose validity is not supported by a review of the clinical literature (Psychiatric News, October 18, 2002).The three practices are routine and concomitant use of more than one atypical antipsychotic for more than a reasonable crossover period (60 days), use of two selective serotonin reuptake inhibitors (SSRIs) for more than 60 days, and concomitant use of five or more psychotropic medications.The work group found that as of January 2002, more than 2,200 adults received more than one atypical antipsychotic at a time for more than 60 days, at a cost of $24 million; that almost 5,000 Medicaid recipients were taking more than one SSRI for more than 60 days, at a cost of more than $4.5 million; and that more than 1,100 MassHealth recipients were receiving five or more psychiatric medications in January, often from multiple prescribers. (MassHealth covers recipients of Medicaid and of benefits from the Children’s State Health Insurance Program.)State officials sent a letter and supporting materials in June to members of MPS and other psychiatrists as a first step to educate them about the lack of clinical evidence for the prescribing practices identified by the work group and to notify the psychiatrists about the threat to Medicaid posed by rising pharmaceutical costs.In August they sent a second letter to 75 psychiatrists whom they had identified as the most frequent users of the three prescribing patterns. They notified them of their status and said the prescribing patterns would be analyzed again in the fall.Annette Hanson, M.D., medical director of the Massachusetts Division of Medical Assistance, told Psychiatric News that her staff had analyzed data about the savings generated by the program up to this past January.“The big savings were in the reduction of the number of patients who were taking five or more psychotropic medications at one time,” she said.The number went from 559 in January 2002 to 25 in January 2003. The cost went from $305,000 a month for the first group to $20,000 a month for the second group.Savings were also generated by a reduction in the number of patients who received more than one atypical antipsychotic at a time for more than 60 days. The number went from 481 to 399, and the cost was reduced from $310,000 to $225,000 per month.Hanson emphasized the importance of advocating for clinical expertise in state Medicaid offices.“Almost no states have well-funded clinical departments to develop and advise on Medicaid policies, but patients and the health care community at large need medical accountability from state officials,” she said.That accountability is particularly important because psychotropic medications account for a large segment of the Medicaid prescription drug budget, which is a key driver of increasing Medicaid costs.Medicaid pharmacy expenditures for the state’s Medicaid population of 940,000 reached $950 million in Fiscal 2002. Forty-seven percent of that figure was spent on medications considered to be primarily psychotropic.“Mental health expenditures account for about 10 percent of the state Medicaid budget,” said Hanson, “but psychotropic medications account for nearly one-half of the Medicaid prescription drug budget.” ▪ ISSUES NewArchived

Using a clinical and evidence-based strategy to preserve access to psychiatric medications.

Using a clinical and evidence-based strategy to preserve access to psychiatric medications.

Pharmacist-Managed Hypertension Therapy Conversion

The cost of treating hypertension represents a substantial percentage of total pharmacy expenditures at medical centers and by managed care organizations in the United States. The present study evaluated improvements in blood pressure control and cost savings achieved by switching 543 hypertensive patients from nifedipine gastrointestinal therapeutic system (GITS) to amlodipine and concurrently instituting an educational program directed at prescribers, nursing and pharmacy staff, and patients and family members. Before the switch, 543 patients were being treated with nifedipine GITS: 259 with 30 mg/d, 209 with 60 mg/d, and 75 with 90 mg/d. The total annual cost of primary antihypertensive therapy for this patient population was $184,698. All patients were switched from nifedipine GITS to 5 mg of amlodipine. The pharmacist saw patients at the time of the switch and at 2, 4, and 6 to 8 weeks after the change in antihypertensive therapy. Patients who did not achieve systolic blood pressure < or = 140 mm Hg or diastolic blood pressure < or = 90 mm Hg by 6 to 8 weeks after the switch were titrated to 10 mg/d amlodipine. After the conversion, 417 patients were receiving amlodipine 5 mg/d and 126 patients were ultimately titrated to 10 mg/d. Measurements made during the first 6 to 8 weeks of treatment indicated that amlodipine therapy significantly reduced blood pressure. Overall, amlodipine produced further mean reductions in blood pressure, from 140/82 to 130/76 mm Hg (p < 0.00005). The mean reduction from the time of the switch to 6 to 8 weeks was from 138/81 to 129/74 mm Hg for the patients who received 5 mg/d amlodipine (p < 0.00001) and from 147/85 to 133/79 mm Hg for the patients ultimately titrated to 10 mg/d amlodipine (p < 0.05). The total annual cost for primary antihypertensive therapy after the conversion was $136,854. We observed that conversion from nifedipine GITS to amlodipine enhanced blood pressure control and saved $47,844 in the annual cost of primary antihypertensive medication. For the 543 patients undergoing the switch, annual cost savings was $47,844. When the cost of additional antihypertensive agents discontinued after the switch to amlodipine was added to the analysis, the net annual cost savings increased to $49,578, a 27% reduction in yearly drug costs.

PHP19: USING FINANCIAL RATIOS TO COMPARE PHARMACY SPENDING IN THE DEPARTMENT OF VETERANS AFFAIRS

OBJECTIVE: To understand how pharmacy spending varies across the VA Medical Centers in the United States. Pharmacy costs continue to rise. From 1990 to 1994 pharmacy expenditures were reported to be 6% of the total Veteran's Health Association (VHA) budget. In 1995 and 1996 it was 7%. In 1997 it was 8% and in 1998 it was 9%. Then in 1999 it went to 11%. Future projections are for a continued increase in budget spending. METHODS: Ratios of yearly Pharmacy to Medical Center expenditures were compared. These ratios were ranked and compared with geographical location. The years of 1997 and 1998 were studied. RESULTS: The majority of the highest ratios were located in the Midwest, Soutwest, and Southern regions of the United States. CONCLUSIONS: Financial ratios can demonstrate variations in expenditures and identify areas that may require further inquiry.

¿Es la cartera de servicios un instrumento útil para la asignación de recursos farmacéuticos en atención primaria?

To find whether in certain primary care teams an association exists between the level of coverage in determined services and expenditure on drugs for pathologies included in these services. Retrospective descriptive study. Primary care, INSALUD, Area 1, Huesca. Using the data on coverage of the service portfolio in 1999 and pharmacy expenditure by therapeutic sub-groups during January-October of the same year, the following was analysed:- The service caring for chronic patients: Hypercholesterolaemia and comparison with expenditure in sub-group B04A (lipid-lowerers/ anti-atheroma drugs).- The service caring for chronic patients: Diabetes and comparison with expenditure in sub-groups A10A (insulin) and A10B (oral antidiabetic drugs). Expenditure was expressed as cost adjusted per 100 insured persons, using the INSALUD coefficients for the adjustment (active person coefficient: 0.732; pensioner coefficient: 0.268). The relationship between the two variables was represented graphically by a cloud of dots. Association between them was measured by Pearson's correlation coefficient. No statistically significant correlation was found between coverage and pharmacy expenditure in these sub-groups. Hypercholesterolaemia/lipid-lowerers: Pearson's coefficient = 0.334, 95% CI (-0.115 to 0.669). Diabetes/oral diabetic drugs and insulin: Pearson's coefficient < 0.1. The differences in coverage of the services analysed bear no direct relationship to pharmacy expenditure. The portfolio of services is not a good method of allocation of pharmaceutical resources.

Reduction in Human Immunodeficiency Virus Patient Hospitalizations and Nontraumatic Mortality after Adoption of Highly Active Antiretroviral Therapy

Highly active antiretroviral therapy (HAART) has been recommended for human immunodeficiency virus (HIV)-positive patients with a detectable viral load; it typically consists of two reverse transcriptase inhibitors combined with a protease inhibitor. In 1996, Madigan Army Medical Center began offering HAART to HIV-positive patients with a detectable viral load. We retrospectively reviewed the records of our HIV patients before and after the initiation of HAART to determine the impact of HAART on hospitalizations, mortality, and outpatient pharmacy expenditures. Comparing 1997 with 1994 and 1995, we found a greater than 700% increase in the average expenditure on antiretroviral agents after institution of HAART. At the same time, we found a dramatic reduction in hospitalizations and nontraumatic mortality. Therefore, the increase in expenditures on antiretroviral agents may be offset by a reduction in hospitalizations and mortality.

A US Military Perspective

This paper discusses lipid therapy decision-making at the population level within the United States (US) Military Health Services System. The US Military Health Services System serves approximately 8.2 million beneficiaries fairly representative of the general population. Of its $680 million annual pharmacy expenditure, $45–$50 million is spent on lipid-lowering drugs. The military Medical Treatment Facilities (MTF) carry a Tri-Service Drug Formulary list, which serves as a bare minimum to which individual facilities may add other agents. The Department of Defense Pharmacoeconomic Center (PEC) performs cost-effectiveness analyses, establishes the Tri-Service Drug Formulary list and the National Mail Order Pharmacy formulary list, and provides drug treatment guidelines. Hyperlipidemia treatment guidelines published by the Pharmacoeconomic Center in 1995, which recommend the use of niacin, colestipol, and pravastatin, are currently under revision to take into consideration new drugs and new information in the field of lipid-lowering therapies. Future changes to the MTF outpatient formulary management may include the introduction of a Basic Core List of essential agents and a Master Pharmaceutical Agent List comprising the only drugs from which facilities may choose to add to their Basic Core List. These changes are designed to standardize drug availability across military facilities to leverage market share for lower drug prices.

The impact of price labeling of muscle relaxants on cost consciousness among anesthesiologists

Study Objective: To determine whether placing price labels on the vial caps of muscle relaxants increases cost consciousness among anesthesiologists. Design: Retrospective study. Setting: University hospital departments of anesthesia and pharmacy. Measurements and Main Results: We placed price labels on the vial caps of all muscle relaxants for a study period of 1 year. At the beginning of the investigation, we informed the anesthesiologists of the study, discussed the prices for different muscle relaxants, and encouraged utilizing less expensive muscle relaxants whenever possible without compromising patient care. The price labels on the vial caps served as visual reminders of the various costs of muscle relaxants during daily practice. We compared the total amount spent on each muscle relaxant during the period from October 1993 to September 1994 with the period from October 1994 to September 1995. The total number of surgical cases from October 1993 to September 1994 and from October 1994 to September 1995 was unchanged and equaled 20,389 and 20,358 cases, respectively. Expenditures for pancuronium increased 104.1%. Total expenditure decreased by 12.5%, with a net savings of $47,111. Conclusion: Expenditures for the less costly pancuronium increased while expenditures for vecuronium and atracurium decreased. Price labeling of muscle relaxants in conjunction with education reduces total pharmacy expenditure on muscle relaxants.