Use of non-formulary high-cost medicines in an Australian public hospital

Background Clinicians prescribe high-cost medicines for rare diseases and nonapproved indications when conventional therapies have failed. Objective To examine the use of non-formulary high-cost medicines at an Australian public hospital. Methods Retrospective audit of individual patient use applications for nonformulary medicines costing more than $5000 AUD per year at a large tertiary referral hospital in Adelaide, South Australia over a 12-month study period from January 2015 to December 2015. Main outcome measures Total cost of non-formulary high-cost medicines, medication class, indications for use, level of supporting evidence and proposed monitoring outcomes. Results Eighty-seven individual patient use applications were examined. All except one were approved, at a total cost of $1,339,203 AUD. The most common drug classes were anti-CD20 (n = 33, 38%), combined antiretrovirals (n = 10, 11%) and TNF-alpha antagonists (n = 10, 11%). There were 56 indications for these medicines with the majority being inflammatory conditions (n = 52, 60%), followed by infections (n = 14, 16%) and malignancies (n = 14, 16%). Of the first-time individual patient use applications (n = 63), there were 25 applications (40%) that provided a case series as supporting evidence. Approximately half of new individual patient use applications (n = 32) proposed an objective monitoring outcome, but few (n = 13, 21%) contained sufficient information to allow a third party to determine efficacy of the medication. Conclusions Non-formulary high-cost medicines are being used for a broad range of indications based largely on low levels of evidence. Prospective definition of an adequate response to treatment and reporting of these outcomes is required to improve the evidence-base and to aid decision-making for subsequent treatment courses.

Priority setting for high cost medications (HCMs) in public hospitals in Australia: A case study

Health care providers (HCPs) are increasingly aware of pressures on funding for health care services, including high cost medicines (HCMs). Allocating resources to innovative and expensive medications is particularly challenging and the decision-making processes and criteria used to allocate resources to HCMs have not been widely described in the literature. This case study aimed to describe the operations of the first reported High Cost Drug Sub-Committee (HCD-SC) in a public hospital in Australia. In addition the study also evaluated the decision-making process using Daniel and Sabin's ethical framework of "accountability for reasonableness". Some lessons emerged from the description of the operations of the HCD-SC. Decisions were not solely based on effectiveness and cost. Additional factors such as "clinical need" and the lack of an alternative treatment were involved in decisions about access to HCMs. Members of the HCD-SC also considered it was important to have consistency in the way decisions were being made. The findings from this study provide an evidence base for developing strategies to improve this hospital's decision-making process regarding access to HCMs.

Public views on priority setting for high cost medications in public hospitals in Australia

OBJECTIVE

To gather information about views of members of the general public about access to High Cost Medications (HCMs) in public hospitals.

METHODS

A structured questionnaire was administered to members of the general public. Individuals were approached in train stations, shopping centres and different venues in the Sydney metropolitan area. People were eligible to answer the survey if they were: over 18 years of age, Australian permanent residents and able to complete the questionnaire in English.

RESULTS

Two hundred people completed the survey. Of these 56% were females, 47% were married, 84% spoke English at home, 88% were working either full-time or part-time, 61% had a university degree, 27% had a household annual income greater than 100,000 dollars and 68% had private health insurance. Participants considered factors such as treatment outcomes, quality of life and current health status when determining who should have access to HCMs. Participants wanted resources to be allocated to provide the 'greatest benefit to the greatest number of people'. Almost half the respondents did not want direct involvement in decision-making, however, 38% did.

CONCLUSIONS

The results offered support for indirect involvement through the development of a process to involve community members in discussion on policy on the provision of treatment and services within health-care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals.