A B S T R A C T S
Quality Improvement Initiatives in a
Managed Care Pharmacy Residency Program
One year ago a managed care pharmacy residency program was developed and implemented in a pharmacy benefits management firm (PBM). The core components of the program were defined—goals and objectives for each rotation, a calendar, assigned preceptors, and an evaluation form. In order to ensure a quality program valued by the resident and the company, continuous quality improvement (CQI) initiatives have been undertaken.
Audience participants will:
Comparison of SF-12 and SF-36 As Generic Health-Related Quality-of-Life Measures in Patients with Osteoarthritis
Sean Zhao, Ph.D.
Searle
The objective of this study was to psychometrically compare SF-12 and SF-36 as generic health-related quality-of-life (HQL) measures in osteoarthritis (OA) patients.
Aggregated data on HQL and clinical measures at baseline and six weeks from three clinical trials examining the efficacy of different NSAIDs in OA patients (n=651) were used. Psy-chometric properties of SF-12 and SF-36 were compared.
SF-12 was comparable to SF-36 in terms of item-missing rate, item-convergent/discriminant validity tests, and item-component correlation tests. SF-12 and SF-36 component scores could be computed for 91% and 97% of respondents, respectively. No floor or ceiling effects were observed at baseline and week six for SF-12 and SF-36 summary scores. The correlations between SF-12 physical (PCS12) and SF-36 physical (PCS36), and SF-12 mental (MCS12) and SF-36 mental (MCS36) component scores ranged from 0.94–0.96 (p<.0005) at baseline and week six. PCS12 was comparable to PCS36 and MCS12 was comparable to MCS36 in terms of association with clinical variables. In general, the SF-36 Bodily Pain and Social Functioning scales were more responsive than the PCS12 and MCS12, respectively.
The responsiveness of SF-12 component scores is comparable to SF-36 component summary scores in OA patients. The SF-12 promises to be a valuable substitute for SF-36 as a generic HQL measure in OA patients. Due to satisfactory psychometric properties and low response time, SF-12 can be used in the regular monitoring of health status of OA patients.
Dihydropyridine Conversion: Was It a Good Decision?
Allan D. Stowers, M.S., R.Ph.
Pfizer, Inc.
A dihydropyridine formulary conversion program was initiated in June 1997 to switch patients from amlodipine to felodipine.
The objectives of the review were to assess dose titrations, discontinuation rates, concomitant medication use, and medica-tions used to treat comorbid conditions. With this information a cost analysis could then be performed to determine success. Pharmacy prescription records were utilized in this evaluation.
The review discovered a significant increase, from 1.63 to 2.34, in the average number of medications being utilized per patient. The proportion of felodipine patients on concomitant medications (71.6%), was much higher than the 40.1% while on amlodipine. A 15.6% discontinuation rate overall could be traced to the angina patients, who had a 50% felodipine discontinuation rate. Due to concomitant medication use, the overall cost to treat these patients sustained a net increase.
If one views formulary management in fiscal dollars alone, then decreasing the total costs of dihydropyridine use resulted in a successful program. However, formulary management should never be isolated by therapeutic class. Fiscal responsibility is integrated, just as individual patient therapy is often complex. With an overall net increase in drug costs and a significant increase in concomitant medication use, this conversion could be deemed a failure.
Objectives:
Comprehensive Review of Managed Care Formularies in the United States
Robin C. Emigh, R.Ph., M.B.A.
Emron
The purpose of this study is to provide a comprehensive review of the formulary status of managed care plans on a na-tional basis. This review, to be updated annually, provides pharmacy directors with an informative resource for benchmarking their formulary management.
A review of the formulary status of managed care plans on a national basis was conducted with the use of the EMRON/ IMS database of managed care plans and their respective formularies. The database is comprised of up-to-date, specific information on the formulary status of over 700 plans.
This review allows the pharmacy director to look at what is happening with formularies across the country and to bench-mark their formulary decision-making activities against a na-tional comparison across plans. Areas to benchmark include such dimensions as formulary status, cost index, therapeutic classes, formulation restrictions, prescribing limitations, and special prescribing requirements.
The creation, development, and maintenance of a database to provide a comprehensive review of the formularly status of managed care plans will allow pharmacy directors to analyze aggregated data and predict trends; to communicate formulary information to providers across networks; and assist their provider networks with updated information.
Audience participants will:
The Effect of a Closed Formulary on Pharmaceutical Utilization, Expenditures, and Treatment Continuation
Rochelle R. Henderson, M.P.A.
Express Scripts
This study examined the effect of a closed formulary on pharmaceutical utilization, expenditures, and continuation with chronic medications for subjects eligible to receive prescription benefits from Express Scripts, Inc.
For subjects enrolled in a plan with a closed formulary, utilization, expenditures, and medication continuation for nine months following the implementation of a closed formulary were compared to those of a control group that did not have a closed formulary and was located in the same region of the country. The analysis controlled for utilization and expenditures in the nine months preceeding the implementation of the closed formulary and for length of eligibility.
Subjects with a closed formulary had lower pharmaceutical utilization and expenditures, greater prior authorization rates, and lower plan participation rates in the nine months following formulary implementation than subjects without a formulary, after controlling for key patient characteristics. No differences were found in treatment continuation rates, but results varied by length of patient eligibility and therapeutic class.
This study suggests that while formularies are effective tools for controlling plans’ pharmaceutical expenditures, they may have potentially undesirable effects. Decision makers should carefully consider the potential trade-offs between cost savings and patient outcomes before implementing a closed formulary.
Audience participants will:
Unmet Needs in Managed Care for Six Prominent Diseases
Although pharmacy has made great strides in patient outcomes management, unmet needs still remain. The purpose of this research is to identify the most important unmet needs in managed care for six diseases: Alzheimer’s disease, asthma, chronic heart failure, depression, diabetes, and osteoporosis.
This study compares the percent of enrolled members, percent of pharmacy budget, overall satisfaction with patient man-agement from a clinical and management perspective, and level of importance and satisfaction with 20 different management parameters for six prominent disease categories. The qualitative study was conducted by mail in the fourth quarter of 1997 with 36 managed care pharmacy directors, physicians, and administrators. Data were analyzed by each parameter and by functional responsibility of respondent (pharmacy director vs. medical director/administrator).
For each disease studied, the most unsatisfied parameter was: Alzheimer’s disease: pharmacoeconomic studies; asthma: quality-of-life data; chronic heart failure: control of inpatient costs; depression: competitive new drug; diabetes: patient com-pliance with therapy; and osteoporosis: competitive new drug prices. Respondents were most unsatisfied with the management of Alzheimer’s disease, both as clinicians and as managers.
Unmet needs in managed care differ among the six diseases studied. Likewise, pharmacy directors and medical directors differ in their perception of unmet needs. Addressing the major unmet needs in each disease category may lead to im-proved patient care.
Audience participants will:
Reasons Given for Discontinuing Antihypertensive Medications
Using pharmacy claims data, patients were identified who had discontinued pharmacotherapy with one of seven different antihypertensive medications: amlodipine, atenolol, hydrochloro-thiazide/triamterene, lisinopril, losartan, nifedipine, and quin-april. Patients must first have been placed on their agent on any date between January 1 and June 30, 1997. Patients who were found to have discontinued therapy within the analysis period (January 1 to December 31, 1997) were mailed a res-ponse card asking why they stopped taking the medication.
Of the 1,440 response cards mailed 529 were returned with 569 responses. The most common responses were: "off and now back on" (14.6%); "no longer needed" (14.4%); "no longer covered by insurance" (12.5%); doctor said "it’s not working" (12.0%); "side effects were unbearable" (10.2%); "using as needed" (8.1%); patient feels "it’s not working" (5.1%); "don’t know why I quit" (3.5%); and "using samples from my doctor" (2.5%).
There was no statistically significant difference found in rates of discontinuation or reasons for discontinuation between the seven medications.
Audience participants will:
Research Experience and Interests of Managed Care Organizations
The common assumption that managed care organizations (MCOs) are not interested in participating in health care research is unproven and should be tested.
MCOs were surveyed about their experience and interest in research. Plans were asked about research interests and past par-ticipation; research-experienced plans were asked to categorize the research, and research-naive plans were asked about interest in future participation. Data on size, model (e.g., IPA, staff) and for-profit status were collected and analyzed to assess trends.
More large plans (>100,000 members) reported research experience than small plans (39.3% vs. 17.1%). For-profit plans with research experience were more likely than not-for-profits to have only pharmacoeconomic experience (71.4% vs. 46.7%), and less likely to have clinical Phase III/IV experience (53.3% vs. 28.6%). Of experienced IPA/network plans, 92.3% had re-searched pharmacoeconomics only, compared to 14.3% of staff/ group counterparts; 85.7% of experienced staff/group plans reported clinical Phase III/IV research, compared to only 7.7% of experienced IPA/network plans. Research-naive not-for-profit, IPA/network, and small plans were more likely than their counterparts to express interest in future research participation. Plans interested in research were most interested in prevalent, chronic diseases, (e.g., asthma and diabetes).
MCOs may wish to participate in research, especially when the research addresses chronic diseases, and, particularly for IPA/network and for-profit plans, pharmacoeconomics. Large plans may be more likely to have research experience; small, IPA/network and not-for-profit plans may be more likely to express interest in new participation.
Audience participants will learn:
Validation of a Primary Open-Angle Glaucoma Costing Model: Second-Line Latanoprost vs. Dorzolamide vs. Brimonidine, Monotherapy, and In Combination With Beta-Adrenergic Blockers
Gisela Kobelt, M.A., M.B.A.
Health Dynamics International, Ltd.
The objective was to validate the assumptions of a Markov Model that estimates the impact of new drugs on the cost to payors of treating newly diagnosed glaucoma patients.
Three cohorts of patients based on the presence of a prescription claim for latanoprost, dorzolamide, or brimonidine in September 1997, were selected from the glaucoma therapeutic class of the PCS Data Warehouse. Claims histories for 12 months (January through December 1997) were used to assess prescribing and usage patterns for random samples of the three cohorts. Days per bottle, monotherapy or combination therapy status, and time on therapy (a surrogate for effectiveness) were assessed, using the September claim as the key date. These data elements were then applied to the interactive Markov Model.
The average number of days between refills was 45, 31, and 28 for latanoprost 2.5 ml, dorzolamide 5 ml, and brimonidine 5 ml, respectively. Latanoprost was used as second-line mono-therapy 43% of the time, while for dorzolamide and brimonidine the proportions were 14% and 31%, respectively. The proportion of patients continuing on treatment for three months or more were latanoprost 85%; dorzolamide 80%; and brimonidine 85%. Applying these parameters to the interactive Markov Model, the average total cost of all resources used to manage a single patient for 12 months was $801.88 with second-line latanoprost; $928.95 for dorzolamide; and $816.66 for brimonidine.
The relative value of total costs for the three treatments based on these actual use data confirm that our model assump-tions do accurately reflect the impact of these drugs on the cost of glaucoma management.
Audience participants will:
Patterns and Costs of Pharmaceutical Care Among Newly Treated Gastroesophageal Reflux Disease (GERD) Patients: H2 Blockers Compared to Proton Pump Inhibitors
The objective of this study was to compare initial medical treatment patterns and the cost of prescription therapy for newly treated GERD patients receiving H2 blockers (H2B) or proton pump inhibitors (PPI).
GERD patients (n=11,302) were identified by ICN-9 codes from an administrative claims database (1994–95). We analyzed H2B and PPI therapy patterns among 3,999 newly treated GERD patients (aged 18–65, stratified by disease severity), each of whom was continuously enrolled, had prescription benefits, and had at least six months of follow-up.
Of these patients, 2,636 (65.9%) intiated therapy with H2B and 1,363 (34.1%) with PPI. Among patients receiving >1 prescription (indicating persistent symptomatic disease) 34.9% of H2B initiators switched therapy, compared to 33.5% of PPI initiators (p=.048). Patients with severe GERD (10.7% of pa-tients) were less likely to switch therapy if initiated on PPI (33.9%) compared to H2B (52.3%) (p=.001).
In contrast, patients with mild to moderate GERD (89.3%) were just as likely to continue initial H2B (66.7%) as initial PPI (66.5%) therapy (p=0.85). For those with mild to moderate GERD the average six-month therapy cost (mean�SD) for H2B initiators ($298�175) was more than $100 lower than for PPI initiators ($420�237).
For newly treated, mild-to-moderate GERD, treatment patterns are similar regardless of initial medication. Prescription expenses were substantially lower for H2B initiators compared to PPI ini-tiators during the six months following the initial prescription.
Audience participants will learn:
CYP3A4: Undetermined Impact on 1.1Million Health Plan Members in Minnesota
Allison Somerville, B.S., R.Ph., Pharm.D.
Candidate University of Minnesota
Coadministration of commonly prescribed medications may result in life-threatening interactions. Recent information has surfaced surrounding cytochrome P450 isoenzymes and has resulted in increased awareness of drug interactions. The purpose of this study is to identify potential risks to 1.1 million lives in a health plan who are receiving one or more drugs inhibiting isoenzyme CYP3A4.
A methodology designed to identify members at risk for drug interactions based on a number of implicated agents was developed. Based on published studies and pharmacokinetic data, as well as analysis of pharmacy and medical data, the number of members at risk will be determined. Utilizing this data, a "relative risk" will be assigned based on identified factors.
Increasing numbers of hospital admissions are attributed to adverse drug reactions. Medical and pharmacy claims, as well as demographics of the populations at highest risk, will be assessed. These factors will be compared against the hospitalizations secondary to adverse drug reactions.
Based on reported numbers, the need to educate practitioners and their patients is evident. Results may allow for educational strategies to be targeted toward the providers of populations at risk.
Audience participants will: