Estimating Tiotropium Wasted Doses After Adding Revefenacin to an Inpatient Formulary: A Single-Center Cross-Sectional Study

Introduction: Revefenacin is a once-daily nebulized long-acting muscarinic antagonist (LAMA). Revefenacin is supplied as single-use nebulized vials, which may be preferable and less costly for hospital and health-system pharmacies to dispense versus multidose tiotropium inhalers. Estimates of LAMA multidose inhaler wasted doses remains unknown. Methods: This was a single-center descriptive cross-sectional study conducted between January 1 2021 and December 31 2021. Adult patients 18 years and older admitted to a 500-bed academic medical center in the southern United States and were ordered multidose tiotropium packages or single-use revefenacin vials during the study period were included. Results: Among 602 inpatients, there were 705 LAMA orders: 541 tiotropium (76.7%) and 164 revefenacin (23.3%). Four hundred ninety-five tiotropium orders (91.5%) wasted between 20% and 90% of multidose packages. Approximately $24,000 tiotropium doses were wasted versus single-use revefenacin vials. Conclusion: Multidose inhalers of tiotropium dispensed to hospitalized patients contributed to wasted doses compared to nebulized single-use revefenacin vials. Opportunities exist to minimize wasted doses of multidose long-acting inhalers dispensed to hospitalized patients.

Minimization of preventable drug waste through use of a vial combination calculator tool

PURPOSE

This project aimed to determine whether a supportive calculator that automates the vial selection process might offer a practical and efficient method of reducing pharmaceutical expenditures through minimizing preventable drug waste in outpatient pharmacy settings.

SUMMARY

Drug waste is a substantial target of cost-saving efforts in the areas of oncology and autoimmune therapy, which involve use of a vast number of high-cost medications packaged in single-dose vials of varying strength. To facilitate selection of the optimal combination of medication vials and thereby minimize preventable drug waste, a Microsoft Excel-based calculator was developed for use by staff of a large oncology pharmacy network. Twenty-three high-cost chemotherapy and monoclonal antibody medications were identified as initial targets for the drug waste prevention initiative. After dissemination and implementation of the calculator and provision of monthly pharmacy staff education, the dollar value of preventable drug waste and the number of suboptimal vial combination selections were reduced by 51% ($412,300) and 54% (315 selections), respectively, in fiscal year 2022 and further reduced by 46% ($183,400) and 27% (71 selections), respectively, in fiscal year 2023.

CONCLUSION

After implementation of an automated vial selection tool, preventable drug waste and the quantity of suboptimal vial combination selections were markedly reduced across 11 outpatient compounding pharmacies.

Identifying and understanding benefits associated with return-on-investment from large-scale healthcare Quality Improvement programmes: an integrative systematic literature review

BACKGROUND

We previously developed a Quality Improvement (QI) Return-on-Investment (ROI) conceptual framework for large-scale healthcare QI programmes. We defined ROI as any monetary or non-monetary value or benefit derived from QI. We called the framework the QI-ROI conceptual framework. The current study describes the different categories of benefits covered by this framework and explores the relationships between these benefits.

METHODS

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar, organisational journals, and citations, using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value) combined with healthcare and QI. Our analysis was informed by Complexity Theory in view of the complexity of large QI programmes. We used Framework analysis to analyse the data using a preliminary ROI conceptual framework that was based on organisational obligations towards its stakeholders. Included articles discussed at least three organisational benefits towards these obligations, with at least one financial or patient benefit. We synthesized the different QI benefits discussed.

RESULTS

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. Included articles were QI economic, effectiveness, process, and impact evaluations as well as conceptual literature. Based on these literatures, we reviewed and updated our QI-ROI conceptual framework from our first study. Our QI-ROI conceptual framework consists of four categories: 1) organisational performance, 2) organisational development, 3) external outcomes, and 4) unintended outcomes (positive and negative). We found that QI benefits are interlinked, and that ROI in large-scale QI is not merely an end-outcome; there are earlier benefits that matter to organisations that contribute to overall ROI. Organisations also found positive aspects of negative unintended consequences, such as learning from failed QI.

DISCUSSION AND CONCLUSION

Our analysis indicated that the QI-ROI conceptual framework is made-up of multi-faceted and interconnected benefits from large-scale QI programmes. One or more of these may be desirable depending on each organisation's goals and objectives, as well as stage of development. As such, it is possible for organisations to deduce incremental benefits or returns-on-investments throughout a programme lifecycle that are relevant and legitimate.

Trends in Canadian prescription drug purchasing: 2001-2020

Background

In 2019, more than $34.5 billion was spent on prescription drugs in Canada. However, little is known about the distribution of this spending across medications and settings (outpatient and inpatient) over time. The objective of this paper is to describe the largest expenditures by medication class over time in inpatient and outpatient settings. This information can help to guide policies to control prescription medication expenditures.

Methods

IQVIA’s Canadian Drugstore and Hospital Purchases Audit data from January 1, 2001, to December 31, 2020, were used. In this dataset, purchasing was stratified by outpatient drugstore and inpatient hospital. Spending trajectories in both settings were compared to total expenditure over time. Total expenditure of the 25 medications with the largest expenditure were compared over time, stratified by setting. Nominal costs were used for all analysis.

Results

In 2001, spending in the outpatient and inpatient settings was greatest on atorvastatin ($467.0 million) and erythropoietin alpha ($91.2 million), respectively. In 2020, spending was greatest on infliximab at $1.2 billion (outpatient) and pembrolizumab at $361.6 million (inpatient). Annual outpatient spending, although increasing, has been growing at a slower rate (5.3%) than inpatient spending (7.0%). In both settings, spending for the top 25 medications has become increasingly concentrated on biologic agents, with a reduction in the diversity of therapeutic classes of agents over time.

Discussion

Identification of the concentration on spending on biologic agents is a key step in managing costs of prescription medications in Canada. Given the increases in spending on biologic agents over the last 20 years, current cost-control mechanisms may be insufficient. Future research efforts should focus on examining the effectiveness of current cost-control mechanisms and identifying new approaches to cost control for biologic agents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-022-00420-4.

Implementation of an ambulatory pharmacy improvement committee across an integrated health system

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications

PURPOSE

Automatic therapeutic substitution (ATS) protocols are formulary tools that allow for provider-selected interchange from a nonformulary preadmission medication to a formulary equivalent. Previous studies have demonstrated that the application of clinical decision support (CDS) tools to ATS can decrease ATS errors at admission, but there are limited data describing the impact of CDS on discharge errors. The objective of this study was to describe the impact of CDS-supported interchanges on discharge prescription duplications or omissions.

METHODS

This was a single-center, retrospective cohort study conducted at an academic medical center. Patients admitted between June 2017 and August 2019 were included if they were 18 years or older at admission, underwent an ATS protocol-approved interchange for 1 of the 9 included medication classes, and had a completed discharge medication reconciliation. The primary outcome was difference in incidence of therapeutic duplication or omission at discharge between the periods before and after CDS implementation.

RESULTS

A total of 737 preimplementation encounters and 733 postimplementation encounters were included. CDS did not significantly decrease the incidence of discharge duplications or omissions (12.1% vs 11.2%; 95% confidence interval [CI], -2.3% to 4.2%) nor the incidence of admission duplication or inappropriate reconciliation (21.4% vs 20.7%; 95% CI, -3.4% to 4.8%) when comparing the pre- and postimplementation periods. Inappropriate reconciliation was the primary cause of discharge medication errors for both groups.

CONCLUSION

CDS implementation was not associated with a decrease in discharge omissions, duplications, or inappropriate reconciliation. Findings highlight the need for thoughtful medication reconciliation at the point of discharge.

Trust your gut: Effect of a pharmacist-driven pilot project to decrease alvimopan use past gastrointestinal recovery in postsurgical patients

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Alvimopan is a peripherally acting opioid receptor antagonist indicated to accelerate gastrointestinal (GI) recovery following surgery, but its benefits past GI recovery are unknown and evidence suggests that it may increase risk for myocardial infarction. The purpose of this study was to evaluate the efficacy of a pilot alvimopan stewardship program aimed at intervening to discontinue alvimopan use following GI recovery.

METHODS

This was a retrospective, observational study examining the first 5 months of the alvimopan stewardship pilot program. During this initial period, a pharmacy resident assessed whether each patient met criteria for GI recovery, defined as solid food toleration and first bowel movement or flatus. If a patient met the criteria for GI recovery, the resident intervened and recommended that the primary team discontinue alvimopan. Primary outcomes were the percentage of patients with alvimopan continued past GI recovery and the percentage of patients for whom alvimopan ordered past GI recovery was discontinued following intervention by stewardship. Secondary outcomes included the percentage of accepted recommendations to discontinue alvimopan following GI recovery and the number of alvimopan doses ordered following GI recovery.

RESULTS

In total, 73 patients were included in the study analysis, all of whom underwent abdominal and/or urologic surgery. Alvimopan was ordered to be administered in 35.6% (26/73) of patients after GI recovery. The stewardship program intervened and recommended discontinuation on 50% (13/26) of the alvimopan doses ordered past GI recovery. Recommendations were accepted by the primary team for 92.3% (12/13) of the patients. A total of 51 doses of alvimopan were ordered for administration past GI recovery, with an average of 2 doses per patient.

CONCLUSION

A pilot pharmacy-driven alvimopan stewardship program was able to identify and intervene on alvimopan orders continued past GI recovery. Interventions decreasing alvimopan use past GI recovery could be of benefit by minimizing potential risk and decreasing potential costs without a negative impact on patient outcomes.

Impact of non-formulary drugs on pharmacological prescription in hospitalised patients

OBJECTIVES

The growing number of drugs on the market makes it necessary to adapt hospital formularies in order to ensure consistent drug coverage. The aim of this study was to evaluate the impact of the prescription of non-formulary drugs (NFD) on the therapeutic management of admitted patients.

METHODS

This retrospective observational study included NFD prescriptions in patients hospitalised in a tertiary university hospital during the period 2012-2015. NFD prescriptions are displayed on the computerised medical order as a pending alert to be reviewed by the clinical pharmacists, who make a notation to the clinical course that includes a recommendation for an available therapeutic alternative when available in the hospital formulary. The degree of acceptance of the recommendation by physicians is recorded.

RESULTS

Approximately 0.5% of patients hospitalised during the study period were affected by an NFD prescription. A total of 52 (9.5%) NFD were of doubtful therapeutic efficacy, five (0.9%) were non-replaceable drugs and 490 (89.4%) were prescriptions for drugs with an alternative available in the hospital formulary. The acceptance rate for the recommended alternative was 34.9% in the evaluable NFD prescriptions. No correlation was observed between the number of NFD prescriptions or the number of NFD and the availability index (drugs included in the hospital formulary in relation to the total number of drugs marketed).

CONCLUSIONS

The number of patients with a NFD prescription was very low. The lack of correlation between the number of NFD or NFD prescriptions and the availability index demonstrated that the hospital formulary covers practically all therapeutic needs.

Current status of pharmacy services in primary healthcare institutions in Jiangsu Province, China

China is attempting to establish a pharmacy services network in primary healthcare (PHC) institutions. This study investigated the current status of pharmacy services in China. Following a conceptual framework derived from the structure-process-outcome model, a questionnaire was sent to a sample of 700 administrators, 2000 GPs, 2000 pharmacy service providers, 2000 patients with chronic diseases and 2000 patients receiving antibiotic transfusion treatment, selected using a multistage sampling strategy, from PHC institutions in Jiangsu Province, China, in July and August 2016. The installation of pharmaceutical facilities and devices, staffing by pharmaceutical professionals, patterns of pharmacy service provision and the outcomes of these services were assessed using descriptive statistics. There were 8346 respondents from 665 institutions (response rate 95.9%). Pharmaceutical department (63.0%), dispensary (50.2%) and pharmacy intravenous admixture services (54.1%) were not established in many PHC institutions. Dispensing (22.9%), pharmacotherapy consultation for patients (19.3%), drug management (17.4%) and prescription checking (16.5%) were the most important tasks for pharmacy service providers. Patients reported lower satisfaction with the dissemination of information regarding medication use (mean (±s.d.) 8.85±1.00%), the treatment of adverse drug reactions (5.65±0.50%), medical insurance reimbursement (15.25±2.45%) and the convenience of buying drugs (6.35±0.65%). Several issues regarding the facilities and devices related to pharmacy services, the quality and responsibilities of pharmacy service providers and the outcomes of pharmacy services may hamper the development of a pharmacy service system in PHC in China.

Outcomes of Inpatient Administration of Restricted Antineoplastic Medications at a Large Academic Medical Institution

BACKGROUND

Restricting oncology and hematology medications to outpatient infusion centers may be considered when infrequent administration is required, a low risk of serious adverse effects exists, or when prompt amelioration of a condition is not expected. At the University of California, San Diego (UCSD), we created a new formulary status for medications designated "formulary, outpatient-restricted use only." This designation could optimize payer reimbursement, as well as improve patient comfort, by negating the need for inpatient admission. When the inpatient administration of a restricted medication is requested at UCSD, there ensues a loosely defined review process involving an informal conversation between the requesting prescriber and the oncology pharmacy and therapeutics (P&T) chair. Patient outcomes associated with this formulary status and informal request process are limited. The purpose of this study is to describe the use of formulary, outpatient-restricted oncology and hematology medications in the inpatient setting at a single-center, academic, and comprehensive cancer center.

METHODS

A retrospective chart review was conducted between January 1, 2015 and May 1, 2017. The primary outcome was to determine the percentage of formulary, outpatient-restricted oncology or hematology medications that were administered in the inpatient setting and continued to the outpatient setting. Secondary outcomes included overall survival, hospice enrollment, disease progression status, level of evidence supporting the medication usage, and cost.

RESULTS

Twenty-three patients and 24 outpatient-restricted medications met the inclusion criteria. Thirteen (54%) medications were continued upon discharge and eight (33%) were not continued in the outpatient setting. Five of those eight medications were discontinued as a result of patient death.

CONCLUSION

In this single-center study, approximately one-third of the outpatient-restricted medications were not continued upon discharge. The findings suggest that our informal approval process could result in the suboptimal use of formulary outpatient-restricted medications for oncology and hematology indications. A more formalized request process might lead to the more effective utilization of these medications.

Systematic literature review of the methodology for developing pharmacotherapeutic interchange guidelines and their implementation in hospitals and ambulatory care settings

PURPOSE

To summarize literature specific to therapeutic interchange (TI) focusing on methodological approaches in order to develop a list of steps that healthcare facilities can consult when developing pharmacotherapeutic interchange guidelines (PTIGs) in hospitals and primary care centers.

METHODS

A search was conducted in PreMEDLINE, Medline, EMBASE, PsycINFO, and the Cochrane Library up to and including December 2015. PRISMA guidelines were used. The inclusion criteria were articles published on TI: methodology, implementation, guidelines, and position statements of scientific societies. Two authors independently reviewed all articles for eligibility and extracted the data.

RESULTS

A total of 102 articles were selected for full-text review; we included three guidelines on how to effect TI, nine position papers of various scientific societies with regard to TI, two articles dealt exclusively about methodology, three articles consisted of recommendations and perspectives on TI, three articles dealt with legal aspects, four articles examined general implementation procedures, two articles were a post-discharge follow-up of patients who had TI, six were surveys referring to TI, and three were articles on the use of TI in ambulatory care The remaining 67 articles focused on therapeutic groups. Study quality was generally low.

CONCLUSIONS

This review identified articles on TI as published guidelines, recommendations, and studies on TI carried out in hospital settings. As a result, eight fundamental steps were established for obtaining adequate results in the development of TI programs.

Impact of Inpatient Automatic Therapeutic Substitutions on Postdischarge Medication Prescribing

Background: Automatic therapeutic substitution (ATS) is the act of therapeutic interchange, in which patients are transitioned from a nonformulary preadmission medication to an equivalent formulary medication upon admission. ATS protocols are able to provide several benefits; however, if medications are unreconciled at the time of discharge, then use may lead to duplication or omission resulting in adverse outcomes. The objective was to assess the impact of preidentified ATS protocol use during admission on duplication and omission postdischarge. Methods: This study included adults who received a preidentified ATS upon admission. The primary outcome was the incidence of duplication or omission at the time of discharge. The secondary outcome was the incidence of duplication or omission at the time of discharge in moderate-to-high readmission risk patients with completed transitions of care (TOC) services compared with incomplete TOC services. Results: A total of 689 encounters were assessed for appropriate reconciliation, duplication, or omission at time of discharge. The incidence of duplication or omission at the time of discharge was 9% (n = 62). Of the 689 encounters, 287 were assessed for the secondary outcome. The rate of duplication or omission at the time of discharge was 10% (n = 19) in the complete TOC services group and 8% (n = 8) in the incomplete TOC services group (P = .6763). Conclusion: This study identified a high rate of appropriate reconciliation of ATS protocols at the time of discharge, which illustrates ATS protocols are a safe medication use management strategy if implemented as intended.

Prediction of inventory sustainability during a drug shortage

PURPOSE

A methodology for predicting how long the on-hand inventory of a given medication will last during a supply shortage is described; a practical example of application of the methodology is provided.

METHODS

Single-site data on consumption of i.v. tobramycin over an eight-month evaluation period were collected using commercial software that tabulates barcode-assisted medication administration (BCMA) events; administered doses were standardized as 1200-mg "vial-equivalents" and summed over the review period. The total number of vial-equivalents consumed was divided by the number of "non-zero weeks of consumption" (i.e., weeks during which any tobramycin use occurred) to obtain a mean ± S.D. weekly consumption rate; this rate was multiplied by the total i.v. tobramycin on-hand supply (in vial-equivalents) to determine the mean number of potentially sustainable weeks of therapy in the event a shortage were to restrict the future supply of the drug.

RESULTS

Overall, 99.6 vial-equivalents of i.v. tobramycin were used during the evaluation period. The mean ± S.D. number of vial-equivalents used per non-zero week of consumption was 3.11 ± 1.26. A manual count of pharmacy inventory revealed that 102.9 vial-equivalents were available at the time of analysis. The mean predicted duration of supply was 33 weeks (95% confidence interval, -126 to 192 weeks).

CONCLUSION

Available BCMA data on tobramycin consumption over eight months were used to calculate the mean number of weeks the on-hand supply of the drug could be expected to last during a persistent drug shortage.

Simplifying Piperacillin/Tazobactam Dosing: Pharmacodynamics of Utilizing Only 4.5 or 3.375 g Doses for Patients With Normal and Impaired Renal Function

OBJECTIVES

To evaluate the pharmacodynamic exposure of piperacillin/tazobactam across the renal function range using 4.5 or 3.375 g dosing regimens.

METHODS

A 5000-patient Monte Carlo simulation was conducted to determine the probability of achieving 50% free time above the minimum inhibitory concentration ( fT > MIC) for piperacillin. Proposed regimens, using solely 4.5 or 3.375 g strengths, were compared with regimens listed in piperacillin/tazobactam prescribing information over creatinine clearance (CrCl) ranges of 120 mL/min to hemodialysis. The probability of target attainment (PTA) at MICs ≤ 16 μg/mL was compared between proposed and standard regimens.

RESULTS

At CrCl 41 to 120 mL/min, prolonged infusions of 4.5 g (3 hours) and 3.375 g (4 hours) every 6 hours resulted in ≥95% PTA versus ≥76% for standard regimens (0.5 hour). At CrCl 20 to 40 mL/min, 4.5 and 3.375 g every 8 hours as prolonged infusions achieved slightly higher PTA (≥98%) versus standard regimens (≥93%). Similarly, PTA achieved with prolonged infusions of 4.5 and 3.375 g every 12 hours (≥93%) was comparable with those of standard regimens (≥91%) at CrCl 1 to 19 mL/min. In hemodialysis, 100% PTA was achieved with prolonged infusion regimens.

CONCLUSION

Piperacillin/tazobactam regimens designed around the 4.5 or 3.375 g dose and prolonged infusions provided similar or better PTA at MICs ≤ 16 μg/mL compared with standard regimens. These observations may support the stocking and use of a single piperacillin/tazobactam strength to simplify dosing.

An Annual Formulary Review Strategy Implemented by a Saudi Health System

As in the U.S., there is no unified national formulary in Saudi Arabia, so individual institutions must develop their own medication lists. A Saudi health system's strategy for maintaining formulary safety, efficacy, and cost-effectiveness is described.

National trends in prescription drug expenditures and projections for 2016

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2016 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2015 were obtained from the IMS Health National Sales Perspectives database and analyzed. Other factors that may influence drug spending in hospitals and clinics in 2016, including new drug approvals and patent expirations, were also reviewed. Expenditure projections for 2016 were based on a combination of quantitative analyses and expert opinion.

RESULTS

Total U.S. prescription sales in the 2015 calendar year were $419.4 billion, which was 11.7% higher than sales in 2014. Prescription expenditures in clinics and nonfederal hospitals totaled $56.7 billion (a 15.9% increase) and $33.6 billion (a 10.7% increase), respectively, in 2015. In nonfederal hospitals, growth in spending was driven primarily by increased prices for existing drugs. The hepatitis C combination drug ledipasvir-sofosbuvir was the top drug overall in terms of 2015 expenditures ($14.3 billion); in both clinics and nonfederal hospitals, infliximab was the top drug. Individual drugs with the greatest increases in expenditures in 2015 were specialty agents and older generics; these agents are likely to continue to influence total spending in 2016.

CONCLUSION

We project an 11-13% increase in total drug expenditures overall in 2016, with a 15-17% increase in clinic spending and a 10-12% increase in hospital spending. Health-system pharmacy leaders should carefully examine local drug utilization patterns in projecting their own organization's drug spending in 2016.

Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures

PURPOSE

The implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit (ICU) is described.

METHODS

This retrospective study compared the use of i.v. chlorothiazide and i.v. ethacrynic acid in pediatric cardiovascular surgery patients before and after implementation of a diuretic stewardship program. All pediatric patients admitted to the pediatric cardiovascular service were included. The cardiovascular surgery service was educated on formal indications for specific diuretic agents, and the diuretic stewardship program was implemented on January 1, 2013. Under the stewardship program, i.v. ethacrynic acid was indicated in patients with a sulfonamide allergy, and i.v. chlorothiazide was considered appropriate in patients receiving maximized i.v. loop diuretic doses. A detailed review of the pharmacy database and medical records was performed for each patient to determine i.v. chlorothiazide and i.v. ethacrynic acid use and expenditures, appropriateness of use, days using a ventilator, and cardiovascular ICU length of stay.

RESULTS

After implementation of diuretic stewardship, the use of i.v. chlorothiazide decreased by 74% (531 fewer doses) while i.v. ethacrynic acid use decreased by 92% (47 fewer doses), resulting in a total reduction of $91,398 in expenditures on these diuretics over the six-month study period and an estimated annual saving of over $182,000. The median number of days using a ventilator and the length of ICU stay did not differ significantly during the study period.

CONCLUSION

Implementation of a diuretic stewardship program reduced the use of i.v. chlorothiazide and i.v. ethacrynic acid without adversely affecting clinical outcomes such as ventilator days and length of stay in a pediatric cardiovascular ICU.

Analysis of Cost Reduction Techniques Adopted in Hospitals in and Around Pune

Purpose:

The purpose of this study is to analyze the various techniques implemented with respect to cost reduction in privately owned hospitals in and around Pune.

Design/Methodology/Approach:

A total of 30 privately owned hospitals were randomly selected for the purpose of the study. The methodology comprised administering the questionnaire along with a personal interview with the administrative/finance officer. The hospitals included for the study were selected based on the following characteristics: Hospitals with capacity of 50–100 beds were termed as small hospitals and hospitals with more than 100 beds were termed as large hospitals. Further they were segregated as general hospitals (<100 beds) and speciality and super speciality hospital in multiple urban locations. These organizations were for-profit hospitals.

Findings:

The results predominantly highlight the key techniques required to be used by most of the hospitals as the cost reduction method, and also the various aspects on which improvement and further development is required to keep on providing better health care service delivery with effective cost containment in the city of Pune.

A cross-sectional study to evaluate the awareness and attitudes of physicians towards reducing the cost of prescription drugs, Mumbai

BACKGROUND

In India, about half of the total health expenditure is spent on medicines. The projected increase in various diseases coupled with the skyrocketing drug prices have further compounded the drug cost burden. We conducted a study to assess the awareness, attitudes, and practices of physicians with regard to various cost containment measures and the factors affecting them.

METHODS

A cross-sectional, questionnaire-based, observational study was conducted over a period of 3 months among 200 physicians, after permission from the Institutional Ethics Committee, at the Grant Medical College and Sir J J Group of Hospitals, Mumbai. The STROBE (Strengthening The Reporting of OBservational studies in Epidemiology) guidelines were followed.

RESULTS

Cost considerations were important to 97 % of government doctors (GDs) and 72 % of private doctors (PDs). Eighty percent of both GDs and PDs said that safety and efficacy were more important than cost. Seventy-one percent of GDs and 65 % of PDs knew about the various cost reduction methods. Twenty-four percent of GDs and 65 % of PDs said that they graded drugs according to cost. Ninety-four percent of GDs and 73 % of PDs said that patent protection should not be extended to life-saving drugs. Sixty-four percent of GDs and 10 % of PDs, and 20 % of GDs and 10 % of PDs were in favor of the stepwise introduction of drugs and the use of generics, respectively. Factors precluding the use of cheaper alternatives were narrow therapeutic index drugs (43.5 %) and fear of substandard quality (38.5 %).

CONCLUSION

Doctors are indeed concerned about the high cost of drugs. More awareness needs to be created about the use of cheaper generics. The government has a very important role to play in reducing the cost of prescription drugs and making healthcare affordable.

Potential savings associated with drug substitution in Medicare Part D: the Translating Research into Action for Diabetes (TRIAD) study

BACKGROUND

Drug substitution is a promising approach to reducing medication costs.

OBJECTIVE

To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs.

DESIGN

Cross-sectional, simulation analysis.

PARTICIPANTS

Low-income subsidy (LIS) beneficiaries (n = 145,056) and non low-income subsidy (non-LIS) beneficiaries (n = 1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution.

MEASUREMENTS

Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy.

RESULTS

Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries.

CONCLUSIONS

Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.

Biosimilars: Implications for health-system pharmacists

PURPOSE

An update on scientific and regulatory challenges in the rapidly evolving field of biosimilar product development is presented.

SUMMARY

The U.S. market for biosimilar products (i.e., highly similar "follow-on" versions of approved biological drugs) is expected to expand with establishment of an expedited-approval pathway for biosimilars similar to that implemented in European Union countries eight years ago. In 2012, the Food and Drug Administration (FDA) published draft guidance clarifying the requirements of the biosimilars approval pathway; although no biosimilar has yet been approved via that pathway, FDA is engaged in ongoing meetings with a number of potential applicants. Due to molecular differences between innovator products and biosimilar versions, biosimilars are highly sensitive to manufacturing changes that can potentially have important safety and efficacy implications. Establishing the interchangeability of biosimilar and innovator drugs may be difficult at first, and it is possible that some biosimilars might not carry all the same indications for which the reference drug is approved. Pharmaceutical cost savings attained through the use of biosimilars are expected to average 20-30%. With several top-selling biologicals likely to lose patent exclusivity by 2020, health systems should prepare for the availability of new biosimilars by addressing formulary management and therapeutic interchange issues, pharmacovigilance and patient safety concerns, and related financial and operational issues.

CONCLUSION

Over the coming years, biosimilars will present opportunities for health care organizations to manage the growth of pharmaceutical expenditures. Pharmacists can play a key role in preparing health systems for projected rapid expansion in the use of biosimilars and associated medication-use policy challenges.

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.

Taking steps to control costs in the OR

Hospitals continue to be challenged by rising expenses in an environment of moderate reimbursements. Health care costs have increasingly come under scrutiny and, with the advent of health care reform, will continue to be scrutinized. Perioperative nurses play a key role in evaluating product safety, effectiveness and efficiency, environmental concerns, and cost and how these factors affect patient care. Cost-saving opportunities that a hospital product evaluation committee can consider include choosing less expensive but equivalent supplies, comparing the expenses associated with disposable versus reusable products, limiting the use of custom supplies, determining ways to reduce linen use, and changing practices to eliminate products that are found to have little clinical value. Adopting effective product evaluation and purchasing practices can lead to reduced costs without affecting the quality of patient care.

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.

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