Reduce Pharmacy Costs Research Articles

Investigation of the Group Purchasing Structure in the Field of Pharmaceuticals and Medical Devices: The Case of Public Pharmacies.

The supply chain of pharmaceuticals and medical devices takes on critical importance regarding group purchasing, given its contribution to a country's healthcare system. One of the primary loops in this chain is the pharmacy as a supplier of goods to consumers and a buyer of goods from distributors. Given the importance of proper and productive preparation, this study examined the structure of aggregated procurement of drugs and medical supplies in public pharmacies. This study used a qualitative method and interviews to collect the necessary data. Fourteen experts and specialists in the public pharmacy field were interviewed and selected using the purposive sampling method. Finally, the textual data were analyzed using efficient thematic analysis. According to experts, the organizational structure for aggregated procurement of medicines and medical supplies in Iran's public pharmacies can take the form of a headquarters structure, a virtual structure, and a semi-centralized virtual structure. The main requirements for these structures are software infrastructure, a productive workforce, and improved storage methods. According to the majority of experts, the most desirable structure for implementing aggregated procurement in hospital pharmacies is the headquarters structure. The aggregated procurement process can reduce pharmacy costs and increase financial reserves and profitability if adequately implemented and equipped with the necessary infrastructure.

Standardizing pharmaceutical delivery to reduce pharmacy costs while simultaneously reducing missing doses

During a patient’s hospital visit, the hospital pharmacy strives to provide service with minimal missing doses or medication errors. In order to decrease the number of missing doses and medication errors that can occur, pharmacies can use either a robot within the central pharmacy or an automated dispensing cabinet (ADC) on the unit that dispenses individual doses for patients. While the robot and the ADC are more effective than a pharmacy technician, they can be costly to implement. We create a linear model which captures the key aspects of the medication delivery system, both from the pharmacy perspective and the nursing unit perspective. The linear program determines the delivery method for each medication, dose type, and unit in order to minimize the cost to deliver the medication to the patient for a given missing dose rate. Solving this linear program for different missing dose rates produces the tradeoff curve between the minimum cost of delivery and the average number of missing doses. We then create a heuristic to determine the delivery method based on a ratio comparing the delivery cost increase to the missing dose reduction.

Estimated Cost and Savings in a Patient Management Program for Oral Oncology Medications: Impact of a Split-Fill Component.

PURPOSE:A national specialty pharmacy implemented a split-fill option within an oral oncology patient management program to reduce pharmacy costs and medication wastage resulting from early discontinuations. Payers covered dispensed medications at half-quantity intervals for each dispense up to 3 months. Proactive outreach to patients before they had used up the initial dispensed medication quantity helped assess the patient’s tolerance to the new medication and adverse effects. This study compared costs for patients with a split-fill option to similar costs for patients without this option taking into account patient discontinuation rates, patient-reported adverse effects rates, estimated pharmacy costs, and potential wastage.METHODS:This retrospective cohort study included patients who were new to therapy on a split-fill medication between September 2015 and August 2017. A 1:1 greedy match algorithm was conducted using propensity variables to match patients from each cohort. Per-month discontinuation rates were determined for both split-fill and non–split-fill groups. The non–split-fill potential wastage was calculated as monthly costs for discontinuations in the following month and weighted by split-fill discontinuation rates.RESULTS:Of the 2,363 program patients who met selection criteria for the 11 medications, 671 patients from each group were matched. Payers with a split-fill program had significant medication savings per covered month ($2,147.60 at 1 month) and at a cumulative 6 months. Modeled wastage indicated that payers without a split-fill program could expect to save $2,646.74 monthly by using this option. Both cohorts had similar rates of adverse effects and time until first reported adverse effect.CONCLUSION:In the first 6 months, the split-fill patient managed program had lower discontinuation rates, significantly reduced pharmacy costs, and reduced potential wastage.

A systematic review of the effectiveness of policies restricting access to pregabalin

BackgroundFormularies often employ restriction policies to reduce pharmacy costs. Pregabalin, an alpha-2-delta ligand, is approved for treatment of fibromyalgia (FM); neuropathic pain (NeP) due to postherpetic neuralgia (PHN), diabetic peripheral neuropathy (pDPN), spinal cord injury; and as adjunct therapy for partial onset seizures. Pregabalin is endorsed as first-line therapy for these indications by several US and EU medical professional societies. However, restriction policies such as prior authorization (PA) and step therapy (ST) often favor less costly generic pain medications over pregabalin.MethodsA structured literature search (PubMed, past 11 years) was conducted to evaluate whether restriction policies against pregabalin support real-world economic and healthcare utilization benefits.ResultsSearch criteria identified three claims analyses and a modeling study that evaluated patients with NeP and/or FM with and without PA restrictions; three other studies included patients with FM and NeP in plans with ST requirements, and one evaluated a mail order requirement program. All studies evaluated outcomes during follow-up periods of 6 months or longer. Overall, PA, ST, and mail order restriction policies effectively reduced pregabalin usage, but the effects were inconsistent with reducing pharmacy costs and were non-significant for total disease-related medical costs. Two studies (one PA; one ST) reported significantly higher disease-related costs in restricted plans. The modeling study failed to demonstrate cost savings with PA. Opioid usage was higher in PA-restricted plans (two studies). The US Centers for Disease Control and Prevention and several professional NeP guidelines recommend opioid use only in cases when other non-opioid pain therapies have proven ineffective. New US Government taskforce guidelines now seek to reduce opioid exposure. Additionally, in both ST studies, gabapentin utilization (a common ST edit) was significantly increased. Both studies had substantial proportions of FM and pDPN patients and the only pain condition gabapentin is approved to treat in the United States is PHN.ConclusionPA and ST restriction policies significantly decrease utilization of pregabalin, but do not consistently demonstrate cost savings for US health plans. More research is needed to evaluate whether these policies may lead to increased opioid usage as found in some studies.Trial registrationN/A.

The Effect of Formulary Restrictions on Patient and Payer Outcomes: A Systematic Literature Review.

Formulary restrictions are implemented to reduce pharmacy costs and ensure appropriate use of pharmaceutical products. As adoption of formulary restrictions increases with rising pharmacy costs, there is a need to better understand the potential effect of formulary restrictions on patient and payer outcomes. To conduct a systematic literature review that assesses the effect of formulary restrictions on the following outcomes: medication adherence, clinical outcomes, treatment satisfaction, drug utilization, health care resource utilization, and economic outcomes. Studies published in 2005 or later were identified from the MEDLINE, Embase, and Cochrane databases and the National Health Service Economic Evaluation Database, using 2 sets of search terms. A total of 17 formulary restriction terms (e.g., step therapy [ST] and prior authorization [PA]) and 55 outcome terms were included, resulting in 935 unique search term combinations. Two reviewers independently conducted analyses of the titles, abstracts, and full-text articles. The search was limited to English-language articles that evaluated the effect of ST and/or PA placed by U.S. third-party payers on the following outcomes: patient outcomes (medication adherence, clinical outcomes, and treatment satisfaction) and payer outcomes (drug utilization, health care resource utilization, and economic outcomes). Of 2,321 reviewed articles, 59 articles met the study inclusion criteria. The included studies assessed the effect of ST (n = 18), PA (n = 35), or both (n = 6) on medication adherence (n = 14), clinical outcomes (n = 12), treatment satisfaction (n = 2), drug utilization (n = 39), health care resource utilization (n = 18), and economic outcomes (n = 42). The 59 articles measured 164 outcomes across the patient, health care resource utilization, and economic outcome categories of interest. Of the total number of outcomes, 50.6% (n = 83) were negative in direction or were unfavorable, whereas 40.2% (n = 66) were positive in direction or were favorable, when the perspectives of patients and payers were considered. Of the total number of drug utilization outcomes reported (n = 46), the majority showed lower drug utilization (> 90%). However, in some of the articles, pharmacy cost savings resulting from lower drug utilization appeared to be offset by increased medical costs. Formulary coverage decisions may have unintended consequences on patient and payer outcomes despite lower drug utilization and pharmacy cost savings; therefore, careful evaluation of restrictions before policy implementation and continued reevaluation after implementation is warranted. This study was funded by Novartis Pharmaceuticals. Park and Ko are employed by Novartis Pharmaceuticals in East Hanover, New Jersey, and Ko holds stock in Novartis. Raza, George, and Agrawal are employed by Novartis Healthcare in Hyderabad, India. Study concept and design were contributed primarily by Park and Ko, along with the other authors. Raza, George, and Agrawal collected the data, along with Park and Ko. Data interpretation was performed by Agrawal, Raza, George, Park, and Ko. The manuscript was written and revised by Raza, George, and Park, along with Ko and Agrawal. Results from this systematic literature review were presented at the AMCP Annual Meeting 2016; San Francisco, California; April 19-22, 2016.

Impact of Oxycodone HCl Extended-release Formulary Restrictions on Extended-release Opioid Market Share, Healthcare Resource Utilization and Costs in Commercial and Medicare Plans.

Background: Previous research demonstrated that utilization management (UM) such as prior authorization (PA) or non-formulary (NF) restrictions may reduce pharmacy costs when designed and applied appropriately to certain drug classes. However, such access barriers may also have unintended consequences. Few studies systemically analyzed the impact of major UM strategies to extended-release (ER) opioids on different types of health plans. Objective: This study evaluated, from payer perspective, the impact of formulary restrictions (PA, NF, or step therapy [ST]) for branded oxycodone HCl extended release (OER) on market share, and healthcare resource utilization/costs in ER opioids patients for multiple types of health plans in the United States. Methods: This retrospective, longitudinal case-control study analyzed prescription and outpatient medical claims data (2012 to 2015) for adult ER opioid patients from US plans (commercial,/Medicare, national/regional) that instituted OER PA, NF, or ST. Patients from each restricted plan (cases) were matched to patients in an unrestricted plan (controls) on key patient characteristics. ER opioid market share and healthcare resource utilization/costs for both cases and controls were evaluated for the 6-month period before and after the formulary restriction dates. A difference-in-differences (DiD) approach was utilized to evaluate change in the total per patient per month (PPPM) healthcare utilization and costs. Results: The study comprised 1622 (national commercial PA), 2020 (regional commercial PA), 34 703 (national commercial ST), and 4372 (national Medicare NF) cases and equivalent number of controls. OER market share decreased after the formulary restrictions, with the national Medicare NF plan showing the greatest decrease (9.2%). DiD analyses indicated that PPPM office visit change in the PA and NF plans were non-significant (decreased by 0.1 and 0.2, P>0.05), but significant in the ST plan (increased by 0.1, P=0.0001). For most plans, no significant total monthly cost change was observed; PPPM costs decreased by $48.74 and $59.87 in ST and regional PA plans and increased by $37.90 in national NF plans (all P>0.05). Conclusions: This study observed that despite reducing the market share of OER, OER formulary restrictions had negligible impact on overall ER opioid utilization, and did not result in substantial pharmacy/medical cost savings.

The Impact of Infectious Diseases Consultation on the Choice of Antifungal Therapy in Patients With Candidemia

Background Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States. Delay in starting appropriate antifungal therapy in patients with candidemia has been associated with increased mortality rates. The goal of this study was to evaluate the impact of infectious diseases (ID) consultation on the class of antifungal therapy used and on all-cause 90-day mortality in patients with candidemia. Methods Candidemic subjects were retrospectively identified by reviewing our hospital's blood culture log books. Medical records of each subject were reviewed for class and length of antifungal agent used, length of hospitalization, evidence of an ID consultation, and 90-day mortality. Results One hundred sixty-three patients with 182 episodes of candidemia were identified during a 6-year period from January 1, 2008, to December 31, 2013. Infectious diseases consultation resulted in significantly greater use of azole therapy compared with no ID consult (67.7% vs 26.3%, P < 0.0001) and comparable durations of therapy (15.3 vs 12.3 days, P = 0.0885). Conclusions Infectious diseases consultation in patients with candidemia results in a significantly higher rate of fluconazole use and minimally longer durations of antifungal therapy, thereby helping to reduce pharmacy costs.

Economic grand rounds: experience with mandated use of generic medications for patients covered by the mental health safety net.

Reducing pharmacy costs without increasing adverse outcomes would relieve some pressure on mental health budgets. This column describes the experience of a publicly funded provider network in a Michigan county that mandated generic use of psychotropic medications to address financial challenges. The percentage of brand-name medications and cost per prescription declined with the policy change, resulting in lower total pharmacy expenditures. No increase was noted in prescriptions per patient or psychiatric hospitalizations. Changes were sustained after the initial implementation period. Mandating generic use may be feasible as a tool for constraining pharmacy costs in mental health budgets.

Retrospective database analysis of the impact of prior authorization for type 2 diabetes medications on health care costs in a Medicare Advantage Prescription Drug Plan population.

Health plans and pharmacy benefit managers have implemented utilization management strategies for newer type 2 diabetes mellitus (T2DM) medications to control pharmacy expenditures. Little is known about the impact of utilization management strategies on overall health care costs and subsequent use of T2DM medications among members who request, but do not receive, a T2DM medication requiring prior authorization (PA). To examine the relationship between the receipt of a T2DM medication requiring PA, health care costs, and subsequent treatment for T2DM. A retrospective cohort study using pharmacy, medical, and laboratory claims data was conducted among Medicare Advantage Prescription Drug plan members with a denied claim for a T2DM medication requiring PA (sitagliptin, a dipeptidyl peptidase-4 inhibitor [DPP-4i], and exenatide, an incretin mimetic) between January 1, 2008, and June 30, 2009. Subjects were required to have 12 months of continuous enrollment both before and after the index date. The entire study period was 24 months in duration, including a 12-month pre-index and 12-month post-index period. Three cohorts were identified: 1 that received a medication requiring PA (denied claim, subsequent fill) and 2 nonfilling control groups. Both control groups requested a medication requiring PA, as evidenced by the denied claim, but neither received the medication, either because the medication was not authorized or the member chose not to fill. Claims-based estimates were used to infer whether the individual likely met the criteria for PA, with 1 control group designated as having met the claims-based criteria (qualifying nonfilling cohort) and the other not having done so (nonqualifying nonfilling cohort.) The primary endpoint evaluated was the relationship between PA medication fill status and plan-paid costs (medical [including laboratory] and pharmacy) over the 12-month post-denial period, with generalized linear models adjusting for key covariates including demographics, concomitant medications, pre-index costs, pre-index adherence, and comorbidities. The secondary endpoint of T2DM medication use (post-denial) among the 2 nonfilling control groups was also evaluated. There were 1,728 members identified who received medication for T2DM requiring PA (the received authorization cohort) and 2,373 who did not (606 qualifying nonfilling cohort; 1,767 nonqualifying nonfilling cohort.) Cohorts were similar with regard to age and gender, but the nonfilling cohort had more comorbidities. Total unadjusted plan-paid 12-month costs were lowest among the received authorization cohort ($11,739), slightly higher ($11,980) for the qualifying nonfilling cohort, and notably higher for the nonqualifying nonfilling cohort ($12,962), although no differences were statistically significant. After adjusting for key covariates, the difference between the nonqualifying nonfilling cohort ($11,980) and the received authorization cohort ($11,729) was statistically significant (P = 0.034). Large differences in plan-paid medical costs ($10,127 for the nonqualifying nonfilling cohort vs. $8,192 for the received authorization cohort) appeared to drive the overall cost totals and were significant in both the unadjusted (P = 0.005) and adjusted models (P less than 0.001). Pharmacy costs were significantly lower for the nonqualifying nonfilling cohort in the adjusted model and for the qualifying nonfilling cohort in both models (all P less than 0.001), but the lower pharmacy costs were not offset by the higher medical costs. In examining the use of medication for treatment of T2DM following the denied claim, 10.6% of the qualifying nonfilling cohort and 13.4% of the nonqualifying nonfilling cohort added another oral therapy, 10.2% and 5.8% added insulin, and 11.9% and 7.1% had treatment intensification, respectively. More than half (56.1%) of the qualifying nonfilling cohort, but only 32.1% of the nonqualifying nonfilling cohort, maintained current therapy. This study found higher plan-paid health care costs (overall and medical alone) among members who requested a type 2 diabetes medication requiring PA, but never received it, compared with those who qualified for and received the requested medication. A notable number of individuals who were assumed to have met the criteria based on a claims-based equivalent, but who never received the medication, made no change to their current therapy. Failure of a member to take medication deemed necessary by his or her physician could translate to inadequate control of the diabetic condition and result in an excess of resource utilization and costs for treating the disease and associated comorbidities. In light of the present findings, health plans should consider not only the impact of utilization management strategies on reducing pharmacy costs, but the broader implication for overall health care costs and subsequent treatment patterns among members.

PCN40 Year to Year Budget Impact Analysis of Biological Therapies for First-Line Treatment of Metastatic Colorectal Cancer in Spain

Martinez-Amores B1, Mezquita L2, Ibanez de Caceres I3, Ayuso A2, Pena JM4, Perona R3, Grande E5, Belda-Iniesta C6 1Hospital Rey Juan Carlos, Madrid, Spain, 2Centro Integral Oncologico Clara Campal (CIOCC), Madrid, Spain, 3IdiPAZ, Madrid, Spain, 4School of Informatics. UPM, Madrid, Spain, 5Hospital Universitario Ramon y Cajal, Madrid, Spain, 6Centro Integral Oncologico Clara Campal (CIOCC), Madrid, Madrid, Spain OBJECTIVES: In real practice, patients are treated along the entire year so that budget simulations should be adjusted to chronological patterns of oncological assistance. Deferred budget impact analysis is undergone in order to assess longrun economic implications of clinical decisions on first-line mCRC therapies in Spain. METHODS: As metastatic colorectal cancer diagnosis is not affected by seasonal influences, we have created a mathematical model assuming that a single patient is diagnosed every month and this patient has a 53% possibility to harbor a native K-Ras sequence. Calculi were arranged based on median duration of therapy. For bevacizumab-based therapy, budget impact for year t 1 begins at month 5 and beyond. For patients that receive cetuximab-based therapy, budget impact for year t 1 begins at month 7. The same approach was performed for doublets without any monoclonal antibody. Prices for all drugs in Spain were assumed to represent the best-value for each drug including all possibilities to reduce pharmacy costs. For first line, median duration of therapy reported by randomized trials was used to calculate the final budget. 70kg and 1.7 m were used as reference for patient dose calculations. RESULTS: When K-Ras status is not tested and bevacizumab-based schedules are administered to every patient, annual growth of budget increases by 55-60%. If K-Ras status is analyzed and wild-type patients are treated with cetuximab combinations and mutated patients receive bevacizumab, yearly budget growth amounts to 39-41%. Annual budget growth is minimized (25%) when K-Ras wt patients are treated with cetuximab combinations whereas K-Ras mutated tumours received chemotherapy alone. CONCLUSIONS: Duration of therapy plays a key role on budget impact estimations from both overall and year to year perspectives. K-Ras based clinical decisions not only optimize outcomes as measured by response rates but also minimize economic implications on annual budget growths.

Cost-effectiveness analysis of cetuximab and panitumumab as first-line metastatic colorectal cancer therapies in Spain.

e14093 Background: Current practice of clinical oncology is a challenge where increased efficacy of new-targeted therapies is counteracted by increasing costs. International financial crisis forces national health systems to optimize all therapeutic strategies maintaining clinical outcomes. Personalized medicine tries to select specific subpopulation of patients by biomarkers to refine therapeutic algorithms. We have performed a cost-effectiveness analysis to assess incremental cost-effectiveness ratio (ICER) per radiological response (RR) for cetuximab or panitumumab based scheduled as 1st line therapies for mCRC patients in Spain. Methods: Efficacy data were computed from all randomized trials (RT) that guided on-label uses of bevacizumab (K-Ras mut), panitumumab and cetuximab. Non- significant outcomes and toxicity as predictor of efficacy were excluded. Prices for drugs in Spain were assumed to represent the best-value for each drug including all possibilities to reduce pharmacy costs. For 1st line, median duration of therapy reported by RT was used to calculate the final budget. 70kg and 1.7 m were used as reference for patient dose calculations. Results: We simulated 3 main scenarios based on the possibilities of therapy for K-Ras wt patients assuming that all patients harboring a K-Ras mut. tumor received bevacizumab based chemotherapy. So, in scenario A K-Ras wt patients received weekly cetuximab combined with FOLFOX, ORR reaches 54% and global cost per RR sums €36,964. Scenario B: administering panitumumab-FOLFOX yields 51% ORR and € 38,880 per RR. Scenario C: cetuximab biweekly combined with FOLFOX yields 54% and €36,474. ICER for scenario A vs B is estimated at €4,394 per additional response. ICER for scenario C vs B yields a negative value of €4,432 per additional response. Conclusions: 1st line oxalipatin combinations of biweekly cetuximab for wt and bevacizumab for mutated patients optimize cost per additional response rate rather than panitumumab based schedules. Marginal cost differences between cetuximab and panitumumab therapies are exceeded by efficacy gap as measured by response rates in RT.

Year-to-year impact budget analysis of biologic therapies for first-line metastatic colorectal cancer (mCRC) therapy in Spain.

e14144 Background: Pharmacoeconomic studies deal with populations of patients as if they were admitted at the division of medical oncology in the same date. Real patients are treated along the entire year so that budget simulations should be adjusted to chronological patterns of oncological assistance. Deferred budget impact analysis is undergone in order to assess long-run economic implications of clinical decisions on first-line mCRC therapies in Spain. Methods: As metastatic colorectal cancer diagnosis is not affected by seasonal influences, we have created a mathematical model assuming that a single patient is diagnosed every month and this patient has a 53% possibility to harbor a native K-Ras sequence. Calculi were arranged based on median duration of therapy. For bevacizumab-based therapy, budget impact for year t+1 begins at month 5 and beyond. For patients that receive cetuximab-based therapy, budget impact for year t+1 begins at month 7. The same approach was performed for doublets without any monoclonal antibody. Prices for all drugs in Spain were assumed to represent the best-value for each drug including all possibilities to reduce pharmacy costs. For first line, median duration of therapy reported by randomized trials was used to calculate the final budget. 70kg and 1.7 m were used as reference for patient dose calculations. Results: When K-Ras status is not tested and bevacizumab-based schedules are administered to every patient, annual growth of budget increases by 55- 60%. If K-Ras status is analyzed and wild-type patients are treated with cetuximab combinations and mutated patients receive bevacizumab, yearly budget growth amounts to 39-41%. Annual budget growth is minimized (25%) when K-Ras wt patients are treated with cetuximab combinations whereas K-Ras mutated tumours received chemotherapy alone. Conclusions: Duration of therapy plays a key role on budget impact estimations from both overall and year to year perspectives. K-Ras based clinical decisions not only optimize outcomes as measured by response rates but also minimize economic implications on annual budget growths.

Cost-effectiveness analysis per life-year gained based on predictors of response for first-line metastatic colorectal cancer therapy in Spain.

3601 Background: Economic crisis, increasing prevalence and cost of mCRC management endanger availability of biological therapies for public health systems due to budget limitations. We performed a cost-effectiveness analysis based on markers of response/resistance including biological therapies available in Spain for mCRC. Methods: We aimed to calculate incremental cost-effectiveness ratio (ICER) per life-year gained (LYG) and progression-free year gained based on predictive markers for mCRC. Efficacy data include randomized trials (RT) that guided on-label uses of bevacizumab and cetuximab. Control arms from these trials were used as reference to calculate ICERs. Markers of clinical benefit (biological and radiological) were included in this model. Toxicity as predictor of efficacy was excluded for any therapy. Prices for drugs in Spain were assumed to represent the best-value for each drug including all possibilities to reduce pharmacy costs. For 1st line, median duration of therapy reported by RT was used to calculate the final budget. 70kg and 1.7 m were used as reference for patients dose calculations. If accessible, HR for PFS and OS were used instead of medians. Results: K-Ras status and early response measured by CT at 8 weeks were used as predictors of resistance and increased efficacy for cetuximab-based combinations. We have not identified any predictor marker for other drugs from RT. In this regard, FOLFIRI+cetuximab combination obtained an ICER below the widely-proposed Spanish threshold of 30,000 € per LYG if patients harbored wt K-Ras tumors and evidenced an objective response at 8 weeks. Other ICERs for different schedules were too distant from this limit, they will be presented at the meeting. Multivariate analysis confirmed the robustness of results. Conclusions: 1st line FOLFIRI+cetuximab therapy for wt K-Ras patients that get an objective response measured by CT at 8 weeks is the only cost-effective therapy option for mCRC below usual health-economic thresholds for Spain. Our results are critical to design cost-effectiveness based clinical guidelines for mCRC that will contribute to financial sustainability of public health system in Spain.

Pharmacoeconomic analysis for K-Ras status–based decisions for first-line therapy of metastatic colorectal cancer (mCRC) in Spain.

438 Background: Personalized medicine is a challenge for current oncology practice. Nowadays there are no pharmacoeconomic analyses in Spain dealing with the clinical and financial impact secondary to K-Ras based decisions for first-line therapy in mCRC patients. So, this study was aimed to assess the cost- effectiveness of K-Ras status based decisions in first- line therapy of mCRC patients in comparison with non- K-Ras based selection of available therapies. Methods: K-Ras mutation prevalence and efficacy of available therapies (measured as response rate and progression free survival) were extracted from randomized clinical trials (RCT) that allowed on-label use of accessible drugs in Spain. Then, we have simulated all possibilities of combination therapies for first-line mCRC based on K-Ras status (wild- type vs mutated) and confronted with all therapies that could be chosen in absence of K-Ras analysis. Prices for all drugs in Spain were used to assume the best- value for each drug including all possibilities to reduce pharmacy costs. For first line, median duration of therapy reported by RCT was used to calculate the final budget. 70 kg and 1.7 m were used as reference for patients dose calculations. Results: First-line therapy that includes a biological drug in absence of K-Ras status based decisions implies an incremental cost per 1% of increased response rate of 1,237 euros for irinotecan based doublets and 3,193 euros for oxaliplatin based doublets. On the opposite, K-Ras based decisions reduce costs per objective response by 69% and 35% for irinotecan and oxaliplatin- based schedules in K-Ras wild-type population incorporating cetuximab as biological agent. These data mimic all calculi based on incremental costs secondary to improved progression free survival measured as HR when all scenarios without prior determination of K-Ras status were confronted with K-Ras based decisions. Conclusions: K-Ras based decisions reduces costs per objective response as well as per improved progression free survival. The most cost- effective scenario among all simulated was cetuximab in combination with chemotherapy for patients that harbor wt K-Ras mCRC.

Extent of Drug Coverage across Generic Drug Discount Programs offered by Community Pharmacies: A look at five Chronic Conditions

Background: Chronic conditions are expensive to treat because of the ongoing prescription cost burden. Generic drug discount programs (GDDPs) that offer generics at discounted price may prove beneficial to reduce pharmacy costs for the same.
 Objective: The objective of this study was to assess the extent to which GDDPs provide drug coverage for five common chronic conditions.
 Methods: A content analyses of preexisting information was conducted. Extent of coverage based on top 200 generic drugs prescribed during 2008 for the treatment of chronic conditions such as hypertension, mental disorders, arthritis, pulmonary/respiratory conditions, and diabetes were identified. Commonly prescribed medications for these diseases were identified using published peer reviewed clinical guidelines. List of drugs covered under a GDDP for stores, Wal-Mart, Walgreens, CVS, Kroger, HEB, Target, and Randalls were obtained and compared to assess drug coverage by retail dollar sales and sales volume. Descriptive statistics and frequency/percentage of coverage were reported using SAS 9.2.
 Results: GDDPs covered the highest number of drugs for hypertension (21-27 across different GDDPs) and the least (3-5 across different GDDPs) for pulmonary/respiratory conditions. Arthritis (5-11), mental disorders (6-11) and diabetes (5-7) had similar coverage. When compared to the top 200 drugs by retail dollars spent during 2008, hypertension (68%-87%) and diabetes (63%-88%) had the highest coverage followed by respiratory conditions (30%-50%), arthritis (22%-48%), and mental disorders (21%-38%). Similar result was obtained when GDDP coverage was compared with the top 200 generic drugs by sales volume, where diabetes (63-88%) and hypertension (57%-74%) had the highest coverage and mental disorders remained the lowest (23%-37%).
 Conclusion/Implications: Drug coverage in GDDPs varied by pharmacies across the five common chronic conditions evaluated which may limit accessibility of these programs for uninformed consumers. Drug coverage was higher for diabetes and hypertension compared to mental disorders, arthritis, and pulmonary/respiratory conditions. Innovative strategies such as a national GDDP formulary list or internet-based technological tools to help consumers identify comparative drug coverage may be useful to improve access to these medications.
 
 Type: Student Project

Economic Impact of Therapeutic Substitution of a Brand Selective Serotonin Reuptake Inhibitor with an Alternative Generic Selective Serotonin Reuptake Inhibitor in Patients with Major Depressive Disorder

To reduce pharmacy costs, managed care organizations encourage therapeutic substitution from brand to a generic product. However, little is known about whether these cost-containment strategies can also potentially lower total expenditures for payers in treatment of major depressive disorder (MDD). To compare economic outcomes of patients with MDD who were switched from a brand selective serotonin reuptake inhibitor (SSRI) to an alternative generic SSRI for nonmedical reasons versus patients who continued on the brand SSRI. Adult MDD patients in the Ingenix Impact Database (2003-2007) were considered "switchers" if they received treatment with a brand SSRI and were later switched to an alternative generic SSRI for nonmedical reasons. Patients who remained on the brand SSRI (nonswitchers) were matched 1:1 with switchers. All-cause, mental health-related, and MDD-related rates of hospitalizations/emergency department (ED) visits and costs over 6 months were compared both descriptively and by using adjusted regression models. A subgroup analysis on patients who were switched from escitalopram (Lexapro) to an alternative generic SSRI was also performed. The study included 4449 matched pairs. Compared with nonswitchers, switchers had higher risk of all-cause, mental health-related, and MDD-related use of hospitalizations/ED visits (OR 1.15, 1.34, and 1.54, respectively; all p < 0.01) and higher risk-adjusted mental health-related and MDD-related medical costs ($219 and $222, respectively; both p < 0.05). Subgroup analysis on escitalopram showed similar results; switchers experienced higher risk of any-cause, mental health-related, and MDD-related use of hospitalizations/ED visits (OR 1.21, 1.41, and 1.53, respectively; all p < 0.01) and higher risk-adjusted MDD-related medical costs ($151; p < 0.05). Compared with patients who continued on their patented SSRIs, patients who switched to a generic SSRI incurred more resource use of hospitalizations/ED visits and higher MDD-related health-care costs. The effects of therapeutic substitution should be carefully examined, because use of generic alternatives may not be a cost-saving strategy when total health-care costs are considered.

Organizations Issue New C. diff. Guideline

Organizations Issue New C. diff. Guideline

Formulary management as a tool to improve medication use and gain physician support

Q: Physicians can be resistant to formulary management activities focused on reducing pharmacy costs. What can be done to institute needed formulary changes and garner physician support for those actions? A: Historically, hospital pharmacy and therapeutics (P&T) commit- tees have focused principally on cost minimization.1 In this context, formulary management processes, characterized by prescribing restrictions, therapeutic interchanges, and protocols, guide use toward more cost-favorable drugs. Because of an exclusive focus on cost containment and the scrutiny by nonphysician personnel used in such processes, resistance can be elicited by physicians who think P&T committees are responsible for diminishing physician autonomy and authority. 2 Optimally, formulary management should provide quality for patients through the selection of medications that maximize value relative to costs and by making physician involvement integral throughout the process. Formulary management can be used as a way of providing quality and value through its strategies and mechanisms that create efficiencies in the medication-use process (therapeutic interchange) and that guide prescribing physicians (restrictions and guidelines).

Quality and Cost Outcomes of Clinical Pharmacist Interventions in a Capitated Senior Drug Benefit Plan

OBJECTIVES: To measure the cost outcomes of interventions by clinical pharmacists in the drug therapy of high-use patients in a Medicare+Choice managed care health plan. DESIGN: Prospective pre/post design without a control group. SETTING: Ambulatory care setting within an integrated health care delivery system. PARTICIPANTS: 80 patients, aged 65 or older, on five or more medications with a limited prescription drug benefit ($1,000 per year maximum). MEASURES: The study evaluated the impact of drug regimen review and subsequent interventions on prescribing alignment with national and local health-system disease management guidelines, drug selection and appropriate dose, prescription costs per-patient--per-month (PPPM), total medical and drug cost PPPM, number of prescriptions PPPM, and provider/patient satisfaction. Medication appropriateness and compliance were assessed through medical records, prescription claims data, and patient interviews. Recommendations were communicated to the primary care provider for each patient. RESULTS: Of 294 patient conditions, 238 (80.9%) cases were in alignment with national guidelines for treatment pre-intervention; 262 (89.1%) were in alignment post-intervention. This represents a 10.2% relative increase in alignment (p=0.001) with national therapy guidelines. Overall, 206 (73.5%) recommendations were implemented. Average PPPM prescription costs (cost incurred by plan) were $175.70 prior to intervention and $158.66 after. This represents a decrease in average prescription costs PPPM of $17.04 ± 7.01 (p=0.012). The average number of prescriptions PPPM decreased from 7.6 to 7.1 (p=0.001). Total cost of care (includes hospitalizations, pharmacy costs, and all medical encounters), medical encounters, and adverse events did not differ statistically from baseline (p=0.146, p=0.077 and p=0.672, respectively). CONCLUSIONS: Drug regimen review and redesign was successful at reducing pharmacy costs without increasing other health care costs. Most important, drug costs were decreased while adherence to evidence-based national guidelines, an intermediate measure of clinical outcome, and a favorable quality outcome improved.

Using an electronic prescribing system can reduce pharmacy costs,

Using an electronic prescribing system can reduce pharmacy costs,