Comparison of pharmacy services at critical access hospitals and other rural and small hospitals in Illinois

PURPOSE

The results of a survey evaluating pharmacy services and technology use at critical access hospitals (CAHs) and other small and rural hospitals in Illinois are reported.

METHODS

A mail survey was sent to pharmacy directors at 86 CAHs and other rural and small hospitals in Illinois not designated as CAHs. Independent sample t tests and chi-square statistics were used to compare CAHs and non-CAHs in areas such as pharmacy services, staffing, use of technology, and sterile compounding practices.

RESULTS

The survey response rate was 46.5%, with usable data received from 40 hospitals. Analysis of the survey data indicated that hospitals designated as CAHs were significantly less likely than non-CAHs to have automatic therapeutic interchange policies (p = 0.012) and more likely to conduct pharmacist-provided educational programs on medication costs for physicians and other health care personnel (p = 0.037). Relative to non-CAHs, CAHs were significantly less likely to have automated dispensing cabinets (p = 0.016) and to out-source the preparation of sterile products to offsite vendors (p = 0.012); pharmacy directors at CAHs were less likely to report the use of technology for remote medication order entry or review (p = 0.038). At both types of facilities, pharmacists typically have both distributive and clinical responsibilities, and patient-specific clinical pharmacy services (e.g., patient education or counseling, other drug therapy monitoring, medication reconciliation, pharmacokinetic consultations) are offered at similar frequencies.

CONCLUSION

A survey of pharmacy departments at small and rural hospitals in Illinois determined that there were more similarities than differences between CAHs and non-CAHs. The survey indicated significant differences in dispensing processes, the use of technology and drug policy tools, and outsourcing of sterile product preparation.

Calendar time-specific propensity score analysis for observational data: a case study estimating the effectiveness of inhaled long-acting beta-agonist on asthma exacerbations

PURPOSE

Propensity scores (PS) are frequently used in observational studies. PS are usually estimated over the entire study period without consideration of the effect of changing patterns of the included variables over time. This study sought to compare PS estimated using the entire study period (conventional PS) and PS estimated for specific periods (calendar time-specific PS (CTS-PS)), and to determine whether there are differences in estimated treatment effects using these approaches.

METHODS

We conducted a claims data analysis. Asthmatic patients who received an asthma controller during 1997-2008 were included. Exposed patients were those who received an inhaled long-acting beta-2 agonist. Conventional PS used the entire period to estimate a PS for individuals. CTS-PS approach divided the study period into 1-year periods and estimated PS separately for each period. Each individual had two PS. Both PS approaches were used to estimate adjusted hazard ratio (HR) for asthma exacerbations using Cox proportional hazard models.

RESULTS

A total of 288,518 patients with an average age of 11.9 ± 5.8 years were included. The difference between conventional PS and CTS-PS in each period ranged from -0.213 to 0.098. The adjusted HR of conventional PS-matched cohort was 1.20 (95%CI: 1.18-1.22), whereas the estimate for the CTS-PS-matched cohort was 1.24 (95%CI: 1.23-1.37).

CONCLUSION

Focusing on a specific year, there was a difference between conventional PS estimated versus CTS-PS for that year. However, there was minimal effect of CTS-PS on the observed treatment effects compared with conventional PS approach.

Comparative cost analysis of management of secondary hyperparathyroidism with paricalcitol or cinacalcet with low-dose vitamin D in hemodialysis patients

OBJECTIVE

The objective of this analysis was to compare costs of paricalcitol or cinacalcet plus low dose vitamin D, and of phosphate binders, in patients in the IMPACT SHPT study; and to extrapolate those to estimate expected annual maintenance costs.

METHODS

IMPACT SHPT was a 28-week, randomized, open-label trial. Subjects from 12 countries received intravenous (IV) or oral paricalcitol, or oral cinacalcet plus fixed IV doxercalciferol or oral alfacalcidol. The primary end-point was the proportion of subjects who achieved a mean intact parathyroid hormone (iPTH) value of 150-300 pg/mL during weeks 21-28 (evaluation period). This study compares the costs of study drugs and phosphate binders among participants during the study and annualized. This analysis includes only those subjects that reached the evaluation period (134 in each group).

RESULTS

The mean total drug costs over the study period were €2606 (SD = €2000) in the paricalcitol group and €3034 (SD = €3006) in the cinacalcet group (difference €428, p = 0.1712). The estimated annualized costs were €5387 (SD = €4139) in the paricalcitol group and €6870 (SD = €6256) in the cinacalcet group (difference €1492, p = 0.0395). In addition, a significantly greater proportion (p = 0.010) of subjects in the paricalcitol arm (56.0%) achieved an iPTH of 150-300 pg/mL during the evaluation period compared to the cinacalcet arm (38.2%).

LIMITATIONS

This was a secondary analysis of the IMPACT SHPT study which was not designed or powered for costs as an outcome. The dosing of study drugs and phosphate binders in the IMPACT study may not reflect actual practice, and patients were followed for 28 weeks, while the treatment of SHPT is long-term.

CONCLUSION

Patients with SHPT requiring hemodialysis who were treated with a paricalcitol-based regimen for iPTH control had lower estimated annual drug costs compared to those treated with cinacalcet plus low-dose vitamin D.

Risk of arrhythmias associated with ipratropium bromide in children, adolescents, and young adults with asthma: a nested case-control study

STUDY OBJECTIVE

To evaluate the risk of arrhythmias associated with inhaled anticholinergic (IAC) use in young patients with asthma.

DESIGN

Population-based nested case-control study.

DATABASE

IMS LifeLink Health Plan Claims Database.

PATIENTS

Patients 5-24 years of age who were diagnosed with asthma and were new users of asthma controller medications were identified between July 1997 and April 2010. Cases were newly diagnosed with arrhythmia and were matched with up to 10 controls based on age, gender, geographic region, and quarter and year of first controller medication dispensing.

MEASUREMENTS AND MAIN RESULTS

Exposure to IACs was determined in the 180 days prior to the event date, defined as date of arrhythmia claim. Active use was defined as sufficient days' supply of a prescription to extend through the event date. Among 283,429 patients with asthma, 7656 cases were matched to 76,304 controls. Most of those included were female (58.8%) and 12 years or older (73.3%). Active exposure of IACs was observed in 0.69% of cases and 0.18% of controls. Active use was associated with a 1.56-fold increase in arrhythmia risk compared with nonactive users or nonusers (adjusted odds ratio [ORadj ] 1.56, 95% confidence interval [CI] 1.08-2.25]). Risk was highest among active users of ipratropium (ORadj 1.59, 95% CI 1.08-2.33). Active high-dose users of IACs (more than 0.114 mg of ipratropium equivalents) had a 69% increase in risk (ORadj 1.69, 95% CI 1.10-2.59), whereas the added risk for active users receiving low-dose IACs (0.114 mg of ipratropium equivalents or less) was not statistically significant (ORadj 1.22, 95% CI 0.53-2.65).

CONCLUSION

Use of ipratropium bromide was associated with an increased risk of arrhythmias in 12-24-year-old patients with asthma.

The incident user design in comparative effectiveness research

Comparative effectiveness research includes cohort studies and registries of interventions. When investigators design such studies, how important is it to follow patients from the day they initiated treatment with the study interventions? Our article considers this question and related issues to start a dialogue on the value of the incident user design in comparative effectiveness research. By incident user design, we mean a study that sets the cohort's inception date according to patients' new use of an intervention. In contrast, most epidemiologic studies enroll patients who were currently or recently using an intervention when follow-up began. We take the incident user design as a reasonable default strategy because it reduces biases that can impact non-randomized studies, especially when investigators use healthcare databases. We review case studies where investigators have explored the consequences of designing a cohort study by restricting to incident users, but most of the discussion has been informed by expert opinion, not by systematic evidence.

Patient safety-focused medication therapy management: challenges affecting future implementation

OBJECTIVES/BACKGROUND

Lessons learned from the implementation of a pharmacist-delivered medication therapy management (MTM) intervention in primary care (PC) can inform future MTM studies and be adopted into real-world clinical settings. We sought to describe the variations and challenges of patient recruitment, enrollment, MTM pharmacist visits, and telephone follow-up in a 3-arm randomized trial of MTM interventions conducted at 3 health centers.

STUDY DESIGN/METHODS

Using a post-study structured interview, we interviewed study personnel, clinical pharmacists, and investigators about 5 study domains: recruitment, enrollment visits, MTM pharmacist visits, telephone follow-up, and data collection.

RESULTS

All centers screened clinic schedules and conducted queries of administrative databases to identify eligible participants. Patients were recruited either during existing primary care visits or by mailing letters with telephone follow-up. Patients with many medical problems, with transportation difficulties, or who were unaccompanied by a family member were less likely to enroll. MTM visits scheduled separately from other clinic appointments had higher cancellation or no-show rates. Provider response to pharmacist recommendations was low overall but better when the provider was acquainted with the pharmacist who was making contact.

CONCLUSIONS

Off-site implementation of MTM services results in lower participation by patients and providers. Future MTM studies should consider integrating MTM services within the clinic during existing appointments by a pharmacist familiar to the primary care provider.

Projecting future drug expenditures--2012

PURPOSE

Factors likely to influence drug expenditures, drug expenditure trends in 2010 and 2011, and projected drug expenditures for 2012 are discussed.

SUMMARY

Data were analyzed to provide drug expenditure trends for total drug expenditures and the hospital and clinic sectors. Data were obtained from the IMS Health National Sales Perspectives database. From 2009 to 2010, total U.S. drug expenditures increased by 2.7%, with total spending rising from $299.2 billion to $307.5 billion. Drug expenditures in clinics grew by 6.0% from 2009 to 2010. Hospital drug expenditures increased at the moderate rate of 1.5% from 2009 to 2010; through the first nine months of 2011, hospital drug expenditures increased by only 0.3% compared with the same period in 2010. The dominant trend over the past several years is substantial moderation in expenditure growth for widely used drugs, primarily due to the ongoing introduction and wide use of generic versions of high-cost, frequently used medications. At the end of 2010, generic drugs accounted for 78% of all retail prescriptions dispensed. Another pattern is substantial increases in expenditures for specialized medications, particularly in the outpatient setting as growth in prescription drug expenditures for clinic-administered drugs consistently outpaces growth in total expenditures. Various factors are likely to influence drug expenditures in 2012, including drugs in development, the diffusion of new drugs, generic drugs, drug shortages, and biosimilars.

CONCLUSION

For 2012, we project a 3-5% increase in total drug expenditures across all settings, a 5-7% increase in expenditures for clinic-administered drugs, and a 0-2% increase in hospital drug expenditures.

Retracted publications in the drug literature

Recent studies have suggested an increase in the number of retracted scientific publications. It is unclear how broadly the issue of misleading and fraudulent publications pertains to retractions of drug therapy studies. Therefore, we sought to determine the trends and factors associated with retracted publications in drug therapy literature. A PubMed search was conducted to identify retracted drug therapy articles published from 2000-2011. Articles were grouped according to reason for retraction, which was classified as scientific misconduct or error. Scientific misconduct was further divided into data fabrication, data falsification, questions of data veracity, unethical author conduct, and plagiarism. Error was defined as duplicate publication, scientific mistake, journal error, or unstated reasons. Additional data were extracted from the retracted articles, including type of article, funding source, author information, therapeutic area, and retraction issue. A total of 742 retractions were identified from 2000-2011 in the general biomedical literature, and 102 drug studies met our inclusion criteria. Of these, 73 articles (72%) were retracted for a reason classified as scientific misconduct, whereas 29 articles (28%) were retracted for error. Among the 73 articles classified as scientific misconduct, those classified as unethical author conduct (32 articles [44%]) and data fabrication (24 articles [33%]) constituted the majority. The median time from publication of the original article to retraction was 31 months (range 1-130). Fifty percent of retracted articles did not state a funding source, whereas pharmaceutical manufacturer funding accounted for only 13 articles (13%) analyzed. Many retractions were due to repeat offenses by a small number of authors, with nearly 40% of the retracted studies associated with two individuals. We found that a greater proportion of drug therapy articles were retracted for reasons of misconduct and fraud compared with other biomedical studies. It is important for health care practitioners to monitor the literature for retractions so that recommendations for drug therapy and patient management may be modified accordingly.

Anticoagulation patient self-monitoring in the United States: considerations for clinical practice adoption

Systematic management models such as anticoagulation clinics have emerged in order to optimize warfarin effectiveness and to minimize related complications. Most of these models are structured so that patients come to a clinic for in-person testing and evaluation, thus making this model of care difficult to access and time consuming for many patients. The emergence of portable instruments for measuring anticoagulant effect in capillary whole blood made it possible for patients receiving warfarin to self-monitor the effect of their anticoagulant therapy. Self-monitoring empowers patients, offers the advantage of more frequent monitoring, and increases patient convenience by allowing testing at home and avoiding the need for frequent laboratory and clinic visits. Self-monitoring can entail patient self-testing (PST) and/or patient self-management (PSM). Several studies have evaluated and shown the benefit of both PST and PSM models of care when compared with either routine medical care or anticoagulation clinic management of anticoagulation therapy. Self-monitoring (PSM and/or PST) of anticoagulation results in lower thromboembolic events, lower mortality, and no increase in major bleeding when compared with standard care. Despite favorable results and enhanced patient convenience, the adoption of self-monitoring into clinical practice in the United States has been limited, especially in higher risk, disadvantaged populations. Although the emergence of a multitude of novel oral anticoagulants will permit clinicians to better individualize anticoagulant therapy options by choosing the optimum regimen based on individual patient characteristics, it is also expected that traditional agents will continue to play a role in a significant subset of patients. For those patients treated with traditional anticoagulants such as warfarin, future models of care will entail patient-centered management such as PST and PSM. The incorporation of technology (i.e., Web-based expert systems) is expected to further improve the outcomes realized by PST and PSM. Further studies are needed to explore factors that influence the adoption of self-monitoring in the United States and to evaluate the feasibility and implementation in real-life clinical settings.

Prioritizing comparative-effectiveness research topics via stakeholder involvement: an application in COPD

A major priority for funding agencies and researchers involved in comparative-effectiveness research (CER) is to ensure that research questions will produce findings that are relevant and feasible to implement. In this article, we describe a process for involving experts and stakeholders in identifying and prioritizing CER studies, as illustrated by our experience in chronic obstructive pulmonary disease (COPD).

Association between leukotriene-modifying agents and suicide: what is the evidence?

The US FDA has issued safety alerts and required manufacturers of leukotriene-modifying agents (LTMAs), including montelukast, zafirlukast and zileuton, to include suicide and neuropsychiatric events as a precaution in the drug label. This paper reviews the existing evidence on the potential association between the LTMAs and suicidal behaviour. We conducted a literature search of MEDLINE, EMBASE and International Pharmaceutical Abstracts from 1995 to 2010 (inclusive) to identify pertinent studies and reports. We also examined data obtained from the FDA adverse event reporting system. To date, there are no well conducted, comparative, observational studies of this association, and the safety alerts are based primarily on case reports. While the FDA safety alerts apply to all three LTMAs, montelukast (known by its trade name Singulair®) is by far the most widely used of these drugs and most of the reports to date regarding suicide pertain to montelukast. From 1998 to 2009 there were 838 suicide-related adverse events associated with leukotrienes reported to the FDA, of which all but five involved montelukast. Nearly all cases were reported in 2008 and 2009 (96.1%) after the FDA warnings. LTMAs are approved for use in asthma and allergic rhinitis, and are effective drugs. Both of these diseases are also associated with suicide, making confirmation of the association more difficult. Given the lack of good evidence, we recommend that a large observational cohort or case-control study be conducted to quantify the association between LTMAs and suicide. Until then, when prescribing LTMAs, clinicians should consider the potential for suicide and monitor patients who may be at elevated risk carefully for suicidal ideation or psychiatric symptoms associated with suicidal behaviour.

Relationship between leukotriene-modifying agent prescriptions dispensed and rate of suicide deaths by county in the US

BACKGROUND

The US Food and Drug Administration has issued warnings about a potential link between leukotriene receptor-modifying agents (LTMA) and suicide. These warnings are based on case reports and there is controversy about the association. While spontaneous reporting of suicide-related events attributed to LTMA has risen dramatically, these data may be biased by the warnings. The objective of this study was to explore the relationship between LTMA and suicide deaths using event data preceding the Food and Drug Administration warnings.

METHODS

We conducted a mixed-effects Poisson regression analysis of the association between LTMA prescriptions dispensed and suicide deaths at the county level. Counts of suicide deaths in each US county, stratified by race, age group, gender, and year were obtained from the National Center for Health Statistics for the period January 1, 1999 to December 31, 2006. Counts of LTMA prescriptions dispensed in each US county were obtained from IMS Health Incorporated. The model estimated the overall suicide rate conditional on LTMA use, adjusted for age, gender, race, year, and antidepressant utilization. We also assessed the intracounty and intercounty associations.

RESULTS

There were 249,872 suicides in the US between 1999 and 2006, and the annual suicide rate ranged from 11.17 to 11.92 per 100,000 population. There were 118.63, 11.68, and 0.12 million prescriptions dispensed for montelukast, zafirlukast, and zileuton, respectively, between 1999 and 2006. The mean rate of LTMA prescriptions dispensed by county was 42.91 (95% confidence interval [CI] 42.78-43.04), 4.82 (95% CI 4.81-4.84), and 0.05 (95% CI 0.05-0.05) per 1000 for montelukast, zafirlukast, and zileuton, respectively. We found a negative within-county association between the rate of total LTMA prescriptions dispensed and the suicide rate by county (P = 0.0296). This association was primarily driven by montelukast.

CONCLUSION

Our results, while subject to certain limitations, provide preliminary evidence that the association between LTMA and suicide could be different (ie, reduced risk) than that which might be anticipated based on previous warnings. Patient-level research is needed to understand more clearly the association between LTMA and suicide.

The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations

BACKGROUND

Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear.

METHODS

We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics.

RESULTS

The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%).

CONCLUSIONS

Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.

Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: how you count matters

ICD-9-CM diagnosis codes are increasingly used to estimate the burden of disease, as well as to evaluate the quality of care and outcomes of various conditions. Acute exacerbations of COPD (AE-COPD) are common and associated with substantial health and financial burden in the U.S. Whether published algorithms that employ different combinations of ICD-9-CM codes to identify patients hospitalized for AE-COPD yield similar or different estimates of disease burden is unclear. In this study, the Nationwide Inpatient Sample from years 2000-2006 was used to identify and compare the number of hospitalizations, healthcare utilization, and outcomes for patients hospitalized for AE-COPD in the U.S. AE-COPD was identified using five different published ICD-9-CM algorithms. Estimates of the annual number of hospitalizations for AE-COPD in the U.S. varied more than 2-fold (e.g., 421,000 to 870,000 in 2006). Outcomes and healthcare utilization of patients hospitalized for AE-COPD varied substantially, depending on the algorithm used (e.g., in-hospital mortality 2.0% to 5.1%, total hospital days 2.0 to 5.1 million in 2006). Observed trends in the number of hospitalizations over the 7-year period varied depending on which algorithm was used. In conclusion, the estimated health burden and trends in hospitalizations for AE-COPD in the United States differ, depending on which ICD-9-CM algorithm is used. To improve our understanding of the burden of AE-COPD and to ensure that quality of care initiatives are not misdirected, a validated approach to identifying patients hospitalized for AE-COPD is needed.

Cost analysis of flavocoxid compared to naproxen for management of mild to moderate OA

OBJECTIVE

Flavocoxid is a medical food used for the clinical dietary management of osteoarthritis (OA). The acquisition cost of flavocoxid is higher than most traditional, generic NSAIDs. However, flavocoxid may have more favorable gastrointestinal (GI) toxicity resulting in lower overall costs. These costs have not been previously examined. This study provides a decision analytic model to assess the net costs of using flavocoxid for OA from a Medicare perspective.

RESEARCH DESIGN AND METHODS

A decision model was developed to estimate the total costs associated with flavocoxid versus naproxen for the management of Medicare patients with mild to moderate OA. Probabilities were obtained from literature and expert opinion, and costs were obtained from Medicare. Sensitivity analyses were conducted by varying probabilities and costs within clinically relevant ranges.

RESULTS

The base case resulted in flavocoxid having lower total annual costs ($1482 per patient) compared to naproxen ($1592). Flavocoxid remained the lowest cost option when the cost inputs were varied by 25% (above and below the base case), and when the probability of GI events with flavocoxid were varied by 25%. However, when GI rates from the literature and implied relative risks from the expert panel were used, or if the cost of PPIs was $0, then naproxen was the less costly alternative, though saving less than the annual cost of flavocoxid. Key limitations were the limited outcomes in the model (only GI events), lack of consideration of adherence or combination therapy, and the reliance on expert opinion due to a lack of data for flavocoxid.

CONCLUSIONS

In patients over 65 years of age who suffer from mild to moderate OA, flavocoxid may result in lower overall costs, despite a higher acquisition cost. Managed care organizations should consider total health care costs in the decision to include flavocoxid as a covered benefit.

Outcomes associated with tiotropium use in patients with chronic obstructive pulmonary disease

BACKGROUND

To date, there is mixed evidence on the safety and effectiveness of tiotropium. Our objective was to evaluate the comparative effectiveness of regimens containing tiotropium bromide vs other medication regimens for chronic obstructive pulmonary disease (COPD) in real-world clinical settings.

METHODS

We conducted a cohort study on 2 separate cohorts with a diagnosis of COPD in the Veterans Affairs health care system. Patients with a diagnosis of COPD prescribed tiotropium and patients in a historic cohort prior to the introduction of tiotropium were selected for comparison using propensity scores, with the base case including scores from 0.1 to 0.4. Outcomes identified during follow-up were all-cause mortality, COPD exacerbations, and COPD hospitalizations. Exposure to COPD medication regimens was defined in a time-varying manner and Cox proportional hazards regression were used to evaluate outcomes.

RESULTS

For 42 090 patients in the base case, the regimen of tiotropium + inhaled corticosteroids (ICS) + long-acting beta-agonists (LABA) was associated with 40% reduced risk of death (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.45-0.79) compared with ICS + LABA. This combination was associated with reduced rates of COPD exacerbations (HR, 0.84; 95% CI, 0.73-0.97) and COPD hospitalizations (HR, 0.78; 95% CI, 0.62-0.98). Tiotropium in combination with 2 other medications was associated with increased risk of mortality, exacerbations, and hospitalizations.

CONCLUSIONS

When used with ICS and LABA, tiotropium use was associated with a decreased risk of mortality compared with treatment with ICS and LABA. However, this result was not consistent in other medication regimens that included tiotropium [corrected].

Improving the efficiency of distributive and clinical services in hospital pharmacy

Three problems impede the assessment of hospital pharmacy efficiency. First, although multiple efficiency indicators are utilized to measure a large variety of activities, it has not been possible to validly measure overall efficiency. Second, there have been no widely-used clinical activity indicators, so key outputs often have not been accounted for. Third, there has been no effective methodology for identifying when declines in efficiency are normal random variations and when they represent true decreases in performance. This paper presents a procedure that simultaneously addresses these three problems. It analyzes data from a group of U.S. hospital pharmacies that collect an inclusive set of clinical and distributional indicators. It employs Data Envelopment Analysis to develop comprehensive efficiency measures from the numerous outputs and inputs. It applies statistical Panel Data Analysis to estimate confidence intervals within which each pharmacy's true efficiency resides, and to develop control charts for signaling when a pharmacy's efficiency has declined by more than can be attributed to random variation. This integrated efficiency evaluation system is transferable to other hospital pharmacy systems, thereby offering decision makers a better way of measuring, controlling and improving hospital pharmacy efficiency.

Projecting future drug expenditures--2009

PURPOSE

Drug expenditure trends in 2007 and 2008, projected drug expenditures for 2009, and factors likely to influence drug expenditures are discussed.

SUMMARY

Various factors are likely to influence drug expenditures in 2009, including drugs in development, the diffusion of new drugs, drug safety concerns, generic drugs, Medicare Part D, and changes in the drug supply chain. The increasing availability of important generic drugs and drug safety concerns continue to moderate growth in drug expenditures. The drug supply chain remains dynamic and may influence drug expenditures, particularly in specialized therapeutic areas. Initial data suggest that the Medicare Part D benefit has influenced drug expenditures, but the ultimate impact of the benefit on drug expenditures remains unclear. From 2006 to 2007, total U.S. drug expenditures increased by 4.0%, with total spending rising from $276 billion to $287 billion. Drug expenditures in clinics continue to grow more rapidly than in other settings, with a 9.9% increase from 2006 to 2007. Hospital drug expenditures increased at a moderate rate of only 1.6% from 2006 to 2007; through the first nine months of 2008, hospital drug expenditures increased by only 2.8% compared with the same period in 2007.

CONCLUSION

In 2009, we project a 0-2% increase in drug expenditures in outpatient settings, a 1-3% increase in expenditures for clinic-administered drugs, and a 1-3% increase in hospital drug expenditures.

Prioritizing future research on off-label prescribing: results of a quantitative evaluation

STUDY OBJECTIVE

To develop a prioritized list of individual drugs for which future research regarding off-label uses is warranted.

DESIGN

Retrospective, cross-sectional study.

DATA SOURCES

Commercial database that provides ongoing estimates of drug prescribing practices of office-based physicians in the United States and an Internet database of comprehensive evidence-based drug information.

MEASUREMENTS AND MAIN RESULTS

The base analyses incorporated three key factors based on the theory of value of information: volume of off-label use with inadequate evidence, drug safety, and cost and market considerations. Nationally representative prescribing data were used to estimate the number of off-label drug uses by indication from January 1, 2005-June 30, 2007, in the United States, and these indications were then categorized according to the adequacy of scientific support. Black-box warnings and safety alerts, drug cost, date of market entry, and marketing expenditures were also incorporated into the final model to produce a priority score. Sensitivity analyses were conducted by varying key model parameters. Our findings identified a high volume of off-label prescribing in the absence of good evidence for a substantial number of drugs, particularly antidepressants, antipsychotics, and anxiolytic-sedatives. Drugs that consistently ranked high in both our base model and sensitivity analyses were quetiapine, warfarin, escitalopram, risperidone, montelukast, bupropion, sertraline, venlafaxine, celecoxib, lisinopril, duloxetine, trazodone, olanzapine, and epoetin alfa.

CONCLUSION

Future research into off-label drug use should focus on drugs used frequently with inadequate supporting evidence, particularly if further concerns are raised by known safety issues, high drug cost, recent market entry, and extensive marketing. Our quantitative analysis identified particular concerns with the off-label use of antipsychotic and antidepressant drugs. Targeted research and policy activities on our list of prioritized drugs have high potential value.

Impact of secondary hyperparathyroidism on disease progression, healthcare resource utilization and costs in pre-dialysis CKD patients

BACKGROUND AND OBJECTIVES

Secondary hyperparathyroidism (SHPT) can lead to significant morbidity, mortality, and additional healthcare resource utilization in chronic kidney disease (CKD) stage 5. The objective of this study was to examine healthcare costs and utilization, and the risks of dialysis or mortality, among pre-dialysis CKD patients with and without SHPT.

RESEARCH DESIGN AND METHODS

This retrospective cohort study examined insurance claims from 66 644 adult, pre-dialysis, CKD patients with and without SHPT during a 72-month period. Annualized estimates of healthcare costs and utilization, and disease progression to dialysis or death following index CKD diagnosis were compared.

RESULTS

Post-index annualized costs and inpatient healthcare resource utilization was higher in those with SHPT in both unadjusted and adjusted (controlling for gender, age, plan type, payer type, geographic region, physician specialty, pre-index co-morbidities, and pre-index total healthcare costs), and unmatched and matched analyses. Kaplan-Meier analysis demonstrated that the rate of progression to dialysis or death was higher for CKD with SHPT compared to CKD without SHPT, and Cox proportional hazard models suggested that CKD patients with SHPT were more than four to five times as likely to initiate dialysis or die as compared to CKD without SHPT.

CONCLUSION

SHPT in pre-dialysis CKD patients is associated with significantly greater healthcare costs, inpatient hospitalizations, and a faster rate of disease progression compared to pre-dialysis CKD without SHPT. Since observational studies are designed to demonstrate associations rather than causality, further investigation is required to confirm these findings.

Impact of Treatment Guidelines on Clinical and Economic Outcomes of Acute Decompensated Heart Failure

Background:

No data exist that demonstrate the impact of comprehensive acute decompensated heart failure (ADHF) treatment guidelines on clinical and economic outcomes in hospitalized patients with this condition.

Objectives:

To compare clinical and economic outcomes before and after implementation of treatment guidelines for ADHF.

Methods:

A single-center, retrospective, chart review study was conducted in a university hospital. ADHF treatment guidelines were developed and implemented on January 1, 2004. Patients hospitalized for ADHF between January 2003 and November 2004 were identified using the Acute Decompensated Heart Failure Registry. Study periods were 12 months prior to and the 11 months following guideline implementation.

Results:

This cohort was comprised of 683 ADHF hospitalizations (357 preguideline, 326 postguideline); several patients were admitted more than once. There was a trend toward increased use of intravenous vasoactive drugs (VADs) following guideline implementation (19.9% vs 24.2%; p = 0.05). The duration of intravenous VAD use decreased by more than 40% following guideline implementation, but this was not statistically significant after risk adjustment (p = 0.22). The need for intensive care unit monitoring decreased from 45.1% before guideline implementation to 25.3% following guideline implementation (p < 0.02) in patients treated with intravenous VADs. The need for mechanical ventilation was reduced by nearly 80% (p = 0.04) following guideline implementation. Significantly more patients of the postguideline cohort were prescribed β-blockers at discharge (54.9% vs 75.2%; p = 0.0001). Costs were not significantly different between the groups.

Conclusions:

Implementation of ADHF treatment guidelines was associated with reduced need for mechanical ventilation, improved utilization of β-blockers at discharge, and trends toward increased use of intravenous VADs, while not significantly changing total costs. More rigorous studies need to be conducted to estimate the true effect of treatment guidelines on ADHF care and outcomes.

Survey of hospitals for guidelines, policies, and protocols for anticoagulants

PURPOSE

A survey of community hospitals that are part of a national group purchasing organization (GPO) was conducted to assess the formulary status of currently available anticoagulants, assess the current status of anticoagulant prescribing guidelines and the existing scope of such guidelines, and identify perceptions about the appropriateness of the use of anticoagulants in community hospitals in the United States.

METHODS

A Web-based survey of acute care hospitals that were members of a leading health care resource management and GPO was conducted. The survey was sent to 224 hospitals.

RESULTS

Of 224 hospitals, 127 participated in the survey, a response rate of 59.6%. Warfarin, unfractionated heparin (UFH), and enoxaparin were the anticoagulants most commonly included (>80%) on the hospitals' drug formularies. Guidelines relating to the use of UFH and low-molecular-weight heparins (LMWHs) existed in approximately 87.4% and 55.1% of responding hospitals, respectively, followed by warfarin and direct thrombin inhibitors (DTIs) (approximately 44.1% and 30.7%, respectively). Among hospitals without guidelines, 78.2%, 72.1%, 65.4%, 50.0%, and 41.4% reported that such guidelines would be useful if they included LMWHs, warfarin, DTIs, UFH, and fondaparinux, respectively. Guidelines for prophylaxis of venous thromboembolism (VTE), appropriate drug selection, and dosing for VTE prophylaxis and treatment existed in 59.8%, 53.5%, and 43.3% of the hospitals, respectively.

CONCLUSION

The study found that a sizable percentage of the responding community hospitals did not have guidelines, protocols, or policies related to the use of anticoagulants. Further, those hospitals without such guidelines commonly reported a need for clinical practice guidelines.

Examination of state-level changes in the pharmacist labor market using Census data

OBJECTIVE

To examine long-term changes in the U.S. pharmacist labor market across states.

DESIGN

Retrospective cohort study.

SETTING

The United States as a whole and individual states in 1990 and 2000.

PARTICIPANTS

Pharmacists and pharmacy school graduates from Census data and previous research, respectively.

INTERVENTION

Retrospective analysis of 5% Public Use Microdata Samples data on pharmacists from the 1990 and 2000 U.S. Census surveys, information on migration among states between 1995 and 2000, and previous research on pharmacy school graduates.

MAIN OUTCOME MEASURES

Changes in pharmacist counts and wages, as well as migration of pharmacists across states and pharmacy school graduates by state.

RESULTS

From 1990 to 2000, the ratio of pharmacists to 100,000 population increased from 70 to 76, but 13 states experienced declines in this datum, and overall changes in pharmacist counts varied considerably among states. The average wage, expressed in 2000 U.S. dollars, for pharmacists increased from $26.58 per hour to $33.80 per hour (17%), while the average wages of non-pharmacist college graduates increased from $26.37 to only $28.76 (9%). Wage changes varied across states.

CONCLUSION

According to the Census, the number of pharmacists per 100,000 population varied substantially across states. This variance in supply across states is not converging or easily explained. Overall, the shortage had a clear impact on the pharmacist labor market, yet this effect was not consistent across states.