National trends in prescription drug expenditures and projections for 2017

Prescription drug spending by payer: Implications for managed care

Background

Brand-name prescription drugs are an important driver of prescription drug spending, but different payers may bear these costs differentially necessitating different policy goals for each payer. But little is known about how the top 10 selling drugs in the U.S. impact spending across payers.

Objective

To estimate the differential spending burden of top prescription drugs on Medicaid, Medicare, commercial coverage, and out-of-pocket (OOP) spending.

Methods

The percentage of total prescription drug spending, total spending, total prescriptions, and average cost per prescription overall and for each of the following payers - Medicaid, Medicare, private insurance, and OOP - was calculated for each of the top 10 selling prescription drugs using 2017-2019 Medical Expenditure Panel Survey data.

Results

These 10 prescription drugs accounted for average annual spending of $83.4 billion and 19.0% of all prescription drug spending. Medicare tended to contribute the highest fraction of spending. The average annual cost per prescription ranged from $500 for Advair to $7400 for Tecfidera. Significant variation in the average annual number of prescriptions filled was observed, ranging from 1.4 million for Tecfidera to 13.6 million for Lantus.

Conclusions

The findings highlight the significant impact of the top 10 selling prescription drugs on U.S. prescription drug spending. The wide variation in per prescription cost as well as contribution to each payer's prescription drug burden emphasizes how policies targeting top-selling drugs may differentially impact payers as well as how payer-specific policies may differ substantially even for top selling drugs.

The Impact of Intermittent Fasting on Patients With Suspected Gastroesophageal Reflux Disease

GOAL

The aim was to investigate the short-term impact of time restricted feeding on patients with suspected gastroesophageal reflux disease (GERD).

BACKGROUND

Lifestyle modifications are often suggested, but the role of diet in GERD is unclear. Intermittent fasting is popular in the media and has demonstrated potential benefits with weight loss and inflammatory conditions as well as alterations in gastrointestinal hormones.

STUDY

Patients who were referred for 96-hour ambulatory wireless pH monitoring off proton pump inhibitor to investigate GERD symptoms were screened for eligibility. Patients were instructed to maintain their baseline diet for the first 2 days of pH monitoring and switch to an intermittent fasting regimen (16 consecutive hour fast and 8 h eating window) for the second 2 days. Objective measures of reflux and GERD symptom severity were collected and analyzed.

RESULTS

A total of 25 participants were analyzed. 9/25 (36%) fully adhered to the intermittent fasting regimen, with 21/25 (84%) demonstrating at least partial compliance. Mean acid exposure time on fasting days was 3.5% versus 4.3% on nonfasting days. Intermittent fasting was associated with a 0.64 reduction in acid exposure time (95% CI: -2.32, 1.05). There was a reduction in GERD symptom scores of heartburn and regurgitation during periods of intermittent fasting (14.3 vs. 9.9; difference of -4.46, 95% CI: -7.6,-1.32).

CONCLUSIONS

Initial adherence to time restricted eating may be difficult for patients. There is weak statistical evidence to suggest that intermittent fasting mildly reduces acid exposure. Our data show that short-term intermittent fasting improves symptoms of both regurgitation and heartburn.

Predictive modeling of pharmaceutical product removal by a managed aquifer recharge system: Comparison and optimization of models using ensemble learners

Pharmaceutical products (PPs) are emerging water pollutants with adverse environmental and health-related impacts, owing to their toxic, persistent, and undetectable microscopic nature. Globally, increasing scientific knowledge and advanced technologies have allowed researchers to study PP-associated problems and their removal for water reuse. Experimental modeling methods require laborious, lengthy, expensive, and environmentally hazardous lab-work to optimize the process. On the other hand, predictive machine learning (ML) models can trace the complex input-output relationship of a process using available datasets. In this study, ensemble ML techniques, including decision tree (DT), random forest (RF), and Xtreme gradient boost (XGB), were used to explore PP (diclofenac, iopromide, propranolol, and trimethoprim) removal by a managed aquifer recharge (MAR) system. The model input parameters included characteristics of reclaimed water and soil used in the columns, pH, dissolved organic carbon, operating time, nitrogen dioxide, sulfate, nitrate, electrical conductivity, manganese, and iron. The selected PP removal was the model output. Datasets were collected through a one-year experimental study of continuous MAR system operation to predict the removal of PPs. DT, RF, and XGB models were then developed for one of the selected compounds and tested for the others to check the reliability of the ML model results. The developed models were assessed using statistical performance matrices. The experimental results showed >80% removal of propranolol and trimethoprim; however, removal of diclofenac and iopromide was only ≈50% by the MAR system. The proposed DT and RF models presented higher coefficients of determination (R² ≥ 0.92) for diclofenac, propranolol, and trimethoprim than for iopromide (R² ≤ 0.63). In contrast, the XGB model showed better results for diclofenac, iopromide, propranolol, and trimethoprim, with R² values of 0.92, 0.72, 0.96, and 0.97, respectively. Therefore, XGB could be the best predictive model to provide insight into the adaptation of ML models to predict PP removal by the MAR system, thereby minimizing experimental work.

Hidradenitis-suppurativa-bedingte Kosten, ein Plädoyer für Aufmerksamkeit: eine systematische Literaturübersicht

Die Daten zu Hidradenitis suppurativa (HS)-bedingten Kosten sind begrenzt und inhomogen. Sie sind jedoch erheblich. Wir führten eine systematische Sichtung der Literaturberichte durch, in denen finanzielle Daten über jeden Gesundheitsbereich oder andere Ausgaben dokumentiert wurden, die durch HS und/oder HS-bedingte Auswirkungen auf Beschäftigung, Einkommen und persönliches wirtschaftliche Entwicklung entstanden sind (indirekte Kosten). Dafür wurden drei elektronische Datenbanken durchsucht (MEDLINE, ScienceDirect und die Cochrane Library -letzte Suche: 14. September 2021). Alle Kosten wurden inflationsbereinigt (2022) und in US-Dollar umgerechnet. Es wurden 23 Artikel eingeschlossen (18 Krankheitskostenstudien, 4 Beobachtungsstudien und 1 Fallserie), in denen ökonomische Daten von 77.287 HS-Patienten erfasst wurden. Die durch HS entstandenen durchschnittlichen jährlichen Kosten pro Patient reichten von 258 $ bis 8.078 $. Diese Zahl erhöhte sich bei chirurgischen Eingriffen, Krankheitsprogression, Antibiotika-Versagen und bestimmten Begleitkrankheiten. Der kostspieligste Faktor war die stationäre Versorgung, gefolgt von ambulanter und Notfallversorgung. Signifikante Unterschiede wurden zwischen den USA und den übrigen untersuchten Ländern beobachtet. Im Vergleich zu Psoriasis-Patienten waren Krankenhausaufenthalte bei HS wahrscheinlicher, länger und kostspieliger, während die weniger kostspielige ambulante Versorgung bei HS-Patienten verringert war. Das Vermeiden der Krankheitsprogression durch frühzeitige Diagnose und Optimierung der ambulanten dermatologischen Versorgung könnte HS-bedinge Ausgaben reduzieren.

Hidradenitis suppurativa-related expenditure, a call for awareness: systematic review of literature

Data regarding hidradenitis suppurativa (HS)-related expenditure is limited and non-homogeneous, but HS does incur significant expenses. We performed a systematic review of literature reports documenting financial data regarding any healthcare domain or other expenditure incurred by HS and/or HS impact on work, income and personal economic growth (indirect costs). Three electronic databases were searched (MEDLINE, ScienceDirect, and the Cochrane Library - last search date: September 14^th , 2021). All costs were adjusted for inflation (2022) and converted into US dollars. Twenty-three papers were included (18 cost-of-illness studies, 4 observational studies and 1 case series), drawing economic data from 77,287 HS patients. The total mean cost incurred by HS per patient per year ranged from $ 258 to $ 8,078. This number increased in case of surgical intervention, disease progression, antibiotic failure and certain comorbid diseases. The costliest healthcare sector was inpatient care, followed by outpatient and emergency care. Significant differences were observed between the USA and the rest of studied countries. Hospitalization was likelier, lengthier, and costlier for HS compared to psoriasis patients, whereas the less costly outpatient care appeared to be reduced among HS patients. Preventing disease progression by optimizing early diagnosis and dermatology outpatient care could decrease HS-related expenditure.

Medication Use and Storage, and Their Potential Risks in US Households

Background: Medications stored in US households may pose risks to vulnerable populations and the environment, potentially increasing societal costs. Research regarding these aspects is scant, and interventions like medication reuse may alleviate negative consequences. The purpose of this study was to describe medications stored in US households, gauge their potential risk to minors (under 18 years of age), pets, and the environment, and estimate potential costs of unused medications. Methods: A survey of 220 US Qualtrics panel members was completed regarding medications stored at home. Published literature guided data coding for risks to minors, pets, and the environment and for estimating potential costs of unused medications. Results: Of the 192 households who provided usable and complete data, 154 (80%) reported storing a medication at home. Most medications were taken daily for chronic diseases. The majority of households with residents or guests who are minors and those with pets reported storing medications with a high risk of poisoning in easily accessible areas such as counters. Regarding risk to the aquatic environment, 46% of the medications had published data regarding this risk. For those with published data, 42% presented a level of significant risk to the aquatic environment. Unused medications stored at home had an estimated potential cost of $98 million at a national level. Implications/Conclusions: Medications stored at home may pose risks to vulnerable populations and the environment. More research regarding medications stored in households and their risks is required to develop innovative interventions such as medication reuse to prevent any potential harm.

Impact of a commercial accountable care organization on prescription drugs

OBJECTIVE

To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care.

DATA SOURCES/STUDY SETTING

California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs.

STUDY DESIGN

We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending.

DATA COLLECTION/EXTRACTION METHODS

The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area.

PRINCIPAL FINDINGS

The cohort differences in baseline characteristics of 40 483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence.

CONCLUSIONS

Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.

Drug purchase price volatility in an academic medical center

PURPOSE

Inpatient drug purchase price trends at an 811-bed academic medical center are described.

SUMMARY

Recent highly publicized drug price increases by pharmaceutical manufacturers have generated public interest in regulatory solutions to reduce drug costs. Monitoring drug price changes through internal dashboards has been demonstrated to aid in purchasing decisions to reduce the impact of drug price changes on inpatient pharmacy drug budgets. In this research, University of Chicago Medicine created an internal dashboard to detail specific inpatient drug purchase price trends. Dashboard data input included all medications purchased through the organization's group purchasing organization over a 25-month time frame. A total of 69,245 drug purchases of 2,432 unique medications and/or dosage strengths were analyzed in the study. Within the 25-month time period, 706 medications (29%) had a net drug purchase price increase, while 898 (37%) had a net drug purchase price decrease. The range of net price percentage changes for medications with price increases was 0.01% to 733.6%; the range for medications with price decreases was 0.01% to 97.5%.

CONCLUSION

Relative to previous purchase prices, drug purchase prices decreased or remained the same more often than they increased over a 25-month time frame. However, drug purchase price percentage changes were far greater for medications whose prices increased rather than decreased.

Five Year Analysis Assessing the Trend in Prescribing and Expenditures of Oral Oncolytics for Medicare Part D: 2013-2017

INTRODUCTION

Oral oncolytics are becoming a mainstay in oncology, representing first-line therapies for numerous different malignancies. In addition, the cost of oncology drugs has increased dramatically in recent years. Given the increasing number of oral oncolytics available, as well as the increase in medication costs in recent years, it is important to assess the trend in prescriptions and expenditures of these agents.

METHODS

A descriptive retrospective analysis of the Medicare Part D Provider Utilization and Payment Data Public Use File (PUF) was conducted for the years 2013 through 2017. Outcomes of interest included total aggregate prescriptions per year, total aggregate expenditures per year, mean expenditure per prescription per year, and mean expenditure per standardized 30-day prescription per year. Chi-square tests were conducted to assess statistical significance of differences in proportions of prescriptions as well as expenditures between 2013 and 2017.

RESULTS

The number of prescriptions for oral oncolytics dispensed to Medicare Part D beneficiaries increased from 7,017,902 in 2013 to 8,164,883 in 2017. Medicare Part D expenditures for oral oncolytics increased greater than 2.5-fold from $5,631,224,307 in 2013 to $14,422,681,331 in 2017 after adjusting for inflation. The mean expenditure per prescription for oral oncolytics increased from $802 in 2013 to $1,766 in 2017.

CONCLUSIONS

This study found oral oncolytic utilization has been increasing in recent years with a slight, but statistically significant increase in the proportion of oncolytics for all Medicare prescriptions from 2013 through 2017.

Changes in Drug List Prices and Amounts Paid by Patients and Insurers

IMPORTANCE

High out-of-pocket drug costs can cause patients to skip treatment and worsen outcomes, and high insurer drug payments could increase premiums. Drug wholesale list prices have doubled in recent years. However, because of manufacturer discounts and rebates, the extent to which increases in wholesale list prices are associated with amounts paid by patients and insurers is poorly characterized.

OBJECTIVE

To determine whether increases in wholesale list prices are associated with increases in amounts paid by patients and insurers for branded medications.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional retrospective study analyzing pharmacy claims for patients younger than 65 years in the IBM MarketScan Commercial Database and pricing data from SSR Health, LLC, between January 1, 2010, and December 31, 2016. Pharmacy claims analyzed represent claims of employees and dependents participating in employer health benefit programs belonging to large employers. Rebate data were estimated from sales data from publicly traded companies. Analysis focused on the top 5 patent-protected specialty and 9 traditional brand-name medications with the highest total drug expenditures by commercial insurers nationwide in 2014. Data were analyzed from July 2017 to July 2020.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Changes in inflation-adjusted amounts paid by patients and insurers for branded medications.

RESULTS

In this analysis of 14.4 million pharmacy claims made by 1.8 million patients from 2010-2016, median drug wholesale list price increased by 129% (interquartile range [IQR], 78%-133%), while median insurance payments increased by 64% (IQR, 28%-120%) and out-of-pocket costs increased by 53% (IQR, 42%-82%). The mean percentage of wholesale list price accounted for by discounts increased from 17% in 2010 to 21% in 2016, and the mean percentage of wholesale list price accounted for by rebates increased from 22% in 2010 to 24% in 2016. For specialty medications, median patient out-of-pocket costs increased by 85% (IQR, 73%-88%) from 2010 to 2016 after adjustment for inflation and 42% (IQR, 25%-53%) for nonspecialty medications. During that same period, insurer payments increased by 116% for specialty medications (IQR, 100%-127%) and 28% for nonspecialty medications (IQR, 5%-34%).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that drug list prices more than doubled over a 7-year study period. Despite rising manufacturer discounts and rebates, these price increases were associated with large increases in patient out-of-pocket costs and insurer payments.

Paleomedicine and the Evolutionary Context of Medicinal Plant Use

Modern human need for medicines is so extensive that it is thought to be a deep evolutionary behavior. There is abundant evidence from our Paleolithic and later prehistoric past, of survival after periodontal disease, traumas, and invasive medical treatments including trepanations and amputations, suggesting a detailed, applied knowledge of medicinal plant secondary compounds. Direct archeological evidence for use of plants in the Paleolithic is rare, but evidence is growing. An evolutionary context for early human use of medicinal plants is provided by the broad evidence for animal self-medication, in particular, of non-human primates. During the later Paleolithic, there is evidence for the use of poisonous and psychotropic plants, suggesting that Paleolithic humans built on and expanded their knowledge and use of plant secondary compounds.

National trends in prescription drug expenditures and projections for 2019

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2019 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2018 were obtained from the IQVIA National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2019 were also reviewed. Expenditure projections for 2019 for nonfederal hospitals, clinics, and overall (all sectors) were made through a combination of quantitative analyses and expert opinion.

RESULTS

U.S. prescription sales in calendar year 2018 totaled $476.2 billion, a 5.5% increase from 2017 spending. The top 3 drugs by expenditures were adalimumab ($19.1 billion), insulin glargine ($9.3 billion), and etanercept ($8.0 billion). Prescription expenditures in nonfederal hospitals totaled $35.8 billion, a 4.8% increase from 2017. Expenditures in clinics in 2018 increased by 13.0% to $80.5 billion. The increase in spending in nonfederal hospitals was largely driven by new products and increased utilization of existing products. The list of the top 25 drugs by expenditures in nonfederal hospitals and clinics was dominated by specialty drugs.

CONCLUSION

We predict continued moderate growth of 4-6% in overall drug expenditures (across the entire U.S. market). We expect the clinic sector to continue to experience high (11-13%) growth in drug spending in 2019. Finally, for nonfederal hospitals we anticipate growth in the range of 3-5%. These estimates are at the national level. Health-system pharmacy leaders should carefully examine local drug utilization patterns to determine their own organization's anticipated spending in 2019.

Decomposition Analysis of Spending and Price Trends for Biologic Antirheumatic Drugs in Medicare and Medicaid

OBJECTIVE

Billions of public dollars are spent each year on biologic disease-modifying antirheumatic drugs (DMARDs), but the drivers of recent increases in biologic DMARD spending are unclear. This study was undertaken to characterize changes in total spending and unit prices for biologic DMARDs in Medicare and Medicaid programs and quantified the major sources of these spending increases.

METHODS

We accessed drug spending data from years 2012-2016, covering all Medicare Part B (fee-for-service), Medicare Part D, and Medicaid enrollees. After calculating 5-year changes in total spending and unit prices for each biologic DMARD as well as in aggregate, we performed standard decomposition analyses to isolate 4 sources of spending growth: drug prices, uptake (number of recipients), treatment intensity (mean number of doses per claim), and treatment duration (annual number of claims per recipient), both excluding and including time-varying rebates.

RESULTS

From 2012 to 2016, annual spending on public-payer claims for the 10 biologic DMARDs included in this study more than doubled ($3.8 billion to $8.6 billion), with median drug price increases of 51% in Medicare Part D (mean 54%) and 8% in Medicare Part B (mean 21%). With adjustment for general inflation, unit price increases alone accounted for 57% of the 5-year, $3.0 billion spending increase in Part D, while 37% of the spending increase was from increased uptake. Accounting for time-varying rebates, prices were still responsible for 54% of increased spending. Unit prices and spending were lower under Medicaid than under Medicare Part D, though temporal trends and contributors were similar.

CONCLUSION

Postmarket drug price changes alone account for the majority of the recent spending growth in biologic DMARDs. Policy interventions targeting price increases, particularly those under Medicare Part D plans, may help mitigate financial burdens for public payers and biologic DMARD recipients.

Cyberecoethnopharmacolomics

ETHNOPHARMACOLOGICAL RELEVANCE

Development of a new term which describes the contemporary, composite, constituent sciences of ethnopharmacology.

AIM OF THE STUDY

To discuss the polysyllabic term cyberecoethnopharmacolomics in the context of the future of ethnopharmacology in global health care.

MATERIALS AND METHODS

Literature background and assessment from the prior literature, diverse databases, and personal discussions.

RESULTS

The profiles and literature background with contemporary and future thoughts regarding the concepts and practices of cyber-, eco-, ethno-, pharmacol-, and -omics, and their impact in ethnopharmacology for the future are presented in the context of integrated health care systems.

CONCLUSIONS

Ethnopharmacology has a major role to play in global health care if the relevant sciences and cutting-edge technologies can coalesce synergistically as a responsive, evidence-based health care practice.

Variation in Prescription Drug Prices by Retail Pharmacy Type: A National Cross-sectional Study

BACKGROUND

Cash prices for prescription drugs vary widely in the United States.

OBJECTIVE

To describe cash price variation by retail pharmacy type for 10 generic and 6 brand-name drugs throughout the United States and stratified by ZIP code.

DESIGN

Cross-sectional study.

SETTING

Drug pricing data from GoodRx, an online tool for comparing drug prices, representing more than 60 000 U.S. pharmacies (fall 2015).

MEASUREMENTS

Cash prices for a 1-month supply of generic and brand-name drugs were ascertained. Stratified by ZIP code, relative cash prices for groups of generic and brand-name drugs were estimated for big box, grocery-based, small chain, and independent pharmacies compared with a reference group of large chain pharmacies.

RESULTS

Across 16 325 ZIP codes, 68 353 unique pharmacy stores contributed cash prices. When stratified by 5-digit ZIP code, the relative cash prices for generic drugs at big box, grocery-based, small chain, and independent pharmacies compared with those at large chain pharmacies were 0.52 (95% CI, 0.51 to 0.53), 0.82 (CI, 0.81 to 0.83), 1.51 (CI, 1.45 to 1.56), and 1.61 (CI, 1.58 to 1.64), respectively. The relative cash prices for brand-name drugs were 0.97 (CI, 0.96 to 0.97), 1.00 (CI, 0.99 to 1.00), 1.06 (CI, 1.05 to 1.08), and 1.03 (CI, 1.02 to 1.04), respectively.

LIMITATION

Results may not reflect current drug prices and do not account for point-of-sale discounts or price matching that may be offered by smaller pharmacies.

CONCLUSION

Compared with large chains, independent pharmacies and small chains had the highest cash prices for generic drugs and big box pharmacies the lowest. Relative differences in cash prices for brand-name drugs were modest across types of retail pharmacies.

PRIMARY FUNDING SOURCE

Arnold Ventures.

The 340b Program, Contract Pharmacies, Hospitals, and Patients: An Evolving Relationship Impacting Health Care Delivery

The 340B Drug Pricing Program, created by Congress in 1992 through the Veterans Health Care Act, has provided discounted drug prices to hospitals and other health care organizations serving a wide population of low-income patients. Some 340B programs use contract pharmacies, an arrangement whereby the hospital or health care organization signs a contract directly with a pharmacy to provide covered pharmacy services at discounted prices. The federal 340B Drug Pricing Program has provided access to reduced price prescription drugs to more than 35 000 individual health care facilities and sites certified by the US Department of Health and Human Services, and clinics have served more than 10 million people in all 50 states, plus commonwealths and US territories. The 340B program has increased profits for hospitals through contract pharmacies because they have still received the same reimbursement but acquired drugs at a lower rate.

Design characteristics, risk of bias, and reporting of randomised controlled trials supporting approvals of cancer drugs by European Medicines Agency, 2014-16: cross sectional analysis

OBJECTIVE

To examine the design characteristics, risk of bias, and reporting adequacy of pivotal randomised controlled trials of cancer drugs approved by the European Medicines Agency (EMA).

DESIGN

Cross sectional analysis.

SETTING

European regulatory documents, clinical trial registry records, protocols, journal publications, and supplementary appendices.

ELIGIBILITY CRITERIA

Pivotal randomised controlled trials of new cancer drugs approved by the EMA between 2014 and 2016.

MAIN OUTCOME MEASURES

Study design characteristics (randomisation, comparators, and endpoints); risk of bias using the revised Cochrane tool (bias arising from the randomisation process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result); and reporting adequacy (completeness and consistency of information in trial protocols, publications, supplementary appendices, clinical trial registry records, and regulatory documents).

RESULTS

Between 2014 and 2016, the EMA approved 32 new cancer drugs on the basis of 54 pivotal studies. Of these, 41 (76%) were randomised controlled trials and 13 (24%) were either non-randomised studies or single arm studies. 39/41 randomised controlled trials had available publications and were included in our study. Only 10 randomised controlled trials (26%) measured overall survival as either a primary or coprimary endpoint, with the remaining trials evaluating surrogate measures such as progression free survival and response rates. Overall, 19 randomised controlled trials (49%) were judged to be at high risk of bias for their primary outcome. Concerns about missing outcome data (n=10) and measurement of the outcome (n=7) were the most common domains leading to high risk of bias judgments. Fewer randomised controlled trials that evaluated overall survival as the primary endpoint were at high risk of bias than those that evaluated surrogate efficacy endpoints (2/10 (20%) v 16/29 (55%), respectively). When information available in regulatory documents and the scientific literature was considered separately, overall risk of bias judgments differed for eight randomised controlled trials (21%), which reflects reporting inadequacies in both sources of information. Regulators identified additional deficits beyond the domains captured in risk of bias assessments for 10 drugs (31%). These deficits included magnitude of clinical benefit, inappropriate comparators, and non-preferred study endpoints, which were not disclosed as limitations in scientific publications.

CONCLUSIONS

Most pivotal studies forming the basis of EMA approval of new cancer drugs between 2014 and 2016 were randomised controlled trials. However, almost half of these were judged to be at high risk of bias based on their design, conduct, or analysis, some of which might be unavoidable because of the complexity of cancer trials. Regulatory documents and the scientific literature had gaps in their reporting. Journal publications did not acknowledge the key limitations of the available evidence identified in regulatory documents.

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.

Duration of Insulin Supply in Type 1 Diabetes: Are 90 Days Better or Worse Than 30 Days?

OBJECTIVE

There have been few studies regarding the duration of insulin prescriptions and patient outcomes. This study evaluated whether A1C varied with the duration of insulin prescription in patients with type 1 diabetes.

METHODS

We conducted a longitudinal investigation (from 2001 to 2015) within a nationwide private health insurer. A cohort study was first used to compare A1C after 30-day only, 90-day only, and a combination (30-day and 90-day) of insulin prescriptions. Second, a self-controlled case series was used to compare A1C levels after 30-day versus 90-day prescriptions for the same person.

RESULTS

In the cohort study, there were 16,725 eligible patients. Mean A1C was 8.33% for patients with 30-day prescriptions compared to 7.69% for those with 90-day prescriptions and 8.05% for those who had a combination of 30- and 90-day prescriptions (P <0.001). Results were similar when stratified by age and sex. Mean A1C was 7.58% when all prescriptions were mailed versus 8.21% when they were not. In the self-controlled case series, there were 1,712 patients who switched between 30- and 90-day prescriptions. Mean A1C was 7.87% after 30-day prescriptions and 7.69% after 90-day prescriptions (P <0.001). Results were similar when stratified by sex. For this within-person comparison, the results remained significant for those ≥20 years of age (n = 1,536, P <0.001), but not for youth (n = 176, P = 0.972).

CONCLUSION

There was a statistically significant but clinically modest decrease in A1C with 90-day versus 30-day insulin prescriptions in adults. A mailed 90-day insulin prescription may be a reasonable choice for adults with type 1 diabetes.

Creating organizational value by leveraging the multihospital pharmacy enterprise

PURPOSE

The results of a survey of multihospital pharmacy leaders are summarized, and a road map for creating organizational value with the pharmacy enterprise is presented.

SUMMARY

A survey was designed to evaluate the level of integration of pharmacy services across each system's multiple hospitals, determine the most commonly integrated services, determine whether value was quantified when services were integrated, collect common barriers for finding value through integration, and identify strategies for successfully overcoming these barriers. The comprehensive, 59-question survey was distributed electronically in September 2016 to the top pharmacy executive at approximately 160 multihospital systems located throughout the United States. Survey respondents indicated that health systems are taking a wide range of approaches to integrating services systemwide. Several themes emerged from the survey responses: (1) having a system-level pharmacy leader with solid-line reporting across the enterprise increased the likelihood of integrating pharmacy services effectively, (2) integration of pharmacy services across a multihospital system was unlikely to decrease the number of pharmacy full-time equivalents within the enterprise, and (3) significant opportunities exist for creating value for the multihospital health system with the pharmacy enterprise, particularly within 4 core areas: system-level drug formulary and clinical standardization initiatives, supply chain initiatives, electronic health record integration, and specialty and retail pharmacy services.

CONCLUSION

Consistently demonstrating strong organizational leadership, entrepreneurialism, and the ability to create value for the organization will lead to the system-level pharmacy leader and the pharmacy enterprise being well-positioned to achieve positive outcomes for patients, payers, and the broader health system.

Creating a learning organization to help meet the needs of multihospital health systems

PURPOSE

The considerations that leaders of multihospital health systems must take into account in developing and implementing initiatives to build and maintain an exceptional pharmacy workforce are described.

SUMMARY

Significant changes that require constant individual and organizational learning are occurring throughout healthcare and within the profession of pharmacy. These considerations include understanding why it is important to have a succession plan and determining what types of education and training are important to support that plan. Other considerations include strategies for leveraging learners, dealing with a large geographic footprint, adjusting training opportunities to accommodate the ever-evolving demands on pharmacy staffs in terms of skill mix, and determining ways to either budget for or internally develop content for staff development. All of these methods are critically important to ensuring an optimized workforce. Especially for large health systems operating multiple sites across large distances, the use of technology-enabled solutions to provide effective delivery of programming to multiple sites is critical. Commonly used tools include live webinars, live "telepresence" programs, prerecorded programming that is available through an on-demand repository, and computer-based training modules. A learning management system is helpful to assign and document completion of educational requirements, especially those related to regulatory requirements (e.g., controlled substances management, sterile and nonsterile compounding, competency assessment).

CONCLUSION

Creating and sustaining an environment where all pharmacy caregivers feel invested in and connected to ongoing learning is a powerful motivator for performance, engagement, and retention.

Factors Affecting Health Care Provider Knowledge and Acceptance of Biosimilar Medicines: A Systematic Review

BACKGROUND

Newly developed biosimilar agents confer significant cost-saving advantages, yielding the potential to mitigate rising drug costs and expand patient access to care for important biologic therapies. Biosimilar market uptake greatly depends on health care provider willingness to promote, prescribe, and use biosimilars in clinical practice.

OBJECTIVE

To perform a systematic review evaluating current U.S. and European health care provider knowledge, perceptions, and prescribing behaviors of biosimilar medicines to assess the need for clinician-directed biosimilar education.

METHODS

An electronic literature search was conducted using journal databases, including PubMed, Embase, and Cochrane Library. Terms related to biosimilar agents, survey questionnaires, and education were used. Two independent reviewers evaluated 158 citations published from January 1, 2014, to March 5, 2018 that were the result of this search. Studies in English were included if they surveyed U.S. or European physician and/or pharmacist knowledge, attitudes, and/or prescribing preferences of biosimilar drugs. Overall trends in prescribing behavior and perceptions were abstracted.

RESULTS

A total of 20 studies met inclusion criteria. Three studies originated from the United States and 17 were from Europe. Hospital specialists, gastroenterologists, and rheumatologists were the most frequently surveyed practitioners. The percentage of biosimilar prescribing varied widely between countries and within similar practice fields. If used, biosimilars were predominantly prescribed in biologic treatment-naive patients. An overall lack of biosimilar familiarity in U.S. and European health care settings accompanied concerns about biosimilar safety, efficacy, extrapolation, and interchangeability. Detailed descriptions of biosimilar education programs were lacking within the literature.

CONCLUSIONS

Findings from this review indicate that U.S. and European health care providers still approach biosimilar medicines with caution, citing limited biosimilar knowledge, low prescribing comfort, and safety and efficacy concerns as main deterrents for biosimilar use. To realize the full cost-saving potential of biosimilar medicines, clinician-directed biosimilar education will be imperative to address gaps in biosimilar knowledge, facilitate prescribing changes, and ultimately increase biosimilar use.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose.

Spending on Antineoplastic Agents in the United States, 2011 to 2016

PURPOSE:

Recent cancer drug approvals are lauded as being more effective with relatively fewer adverse effects, but these treatments come with a great cost to the US health care system. There is little information on recent trends in actual antineoplastic expenditures representative of the whole US health care system or by sector. Therefore, the objective of this study was to describe antineoplastic expenditures in the United States by year and sector.

METHODS:

This was a retrospective, cross-sectional study of IQVIA (formerly QuintilesIMS) National Sales Perspective data for the period of January 1, 2011, to December 31, 2016. Actual expenditures were totaled by health care sector and calendar year, then adjusted for medical-cost inflation to 2016 dollars. Growth was calculated as the percentage increase from the previous year.

RESULTS:

Total expenditures of antineoplastic agents across all channels grew from $26.8 billion in 2011 to $42.1 billion in 2016. Antineoplastic spending increased 12.2% in 2016 (compared with the previous year), followed by 15.6% in 2015, 13.4% in 2014, 6.3% in 2013, and 0.4% in 2012. Throughout the study period, 96.5% of total antineoplastic expenditures occurred within clinics, mail-order pharmacies, nonfederal hospitals, and retail pharmacies.

CONCLUSION:

Antineoplastic expenditures are expected to increase because of continuing development and approval of costly targeted cancer therapies. Cost containment and utilization management strategies must be balanced so as not to restrict access or disrupt innovation. Future policies should focus on ensuring safe and appropriate use of antineoplastics while balancing long-term drug costs.

Improved Adherence Rates and Clinical Outcomes of an Integrated, Closed-Loop, Pharmacist-Led Oral Chemotherapy Management Program

Purpose:

To address the growing use of oral anticancer therapy, an integrated, closed-loop, pharmacist-led oral chemotherapy management program was created within an academic medical center.

Methods:

An integrated, closed-loop, pharmacy-led oral chemotherapy management program was established. From September 2014 until June 2015, demographic information, rates of adherence, patient understanding of treatment, pharmacist interventions, patient and provider satisfaction, and molecular response rates in patients with chronic myeloid leukemia (CML) were collected.

Results:

After full implementation, 107 patients were enrolled in our oral chemotherapy management program from September 2014 until June 2015. All patients were educated before starting oral chemotherapy, and using pre- and postassessment tests, comprehension of oral chemotherapy treatment increased from 43% to 95%. Patient-reported adherence was 86% and 94.7% for the GI/breast and malignant hematology patient populations, respectively, and these were validated with medication possession ratio, revealing adherence rates of 85% and 93.9% for the GI/breast and malignant hematology patient populations, respectively. A total of 350 encounters with a clinical pharmacist and 318 adverse effects were reported, which led to 235 interventions. This program led to a higher major molecular response rate (83%) in our CML population compared with published clinical trials (average major molecular response rates, 40% and 60% with 1- and 2-year follow-up, respectively).

Conclusion:

An innovative model was developed and resulted in improved patient knowledge regarding oral chemotherapy, improved adherence rates that exceeded nationally established thresholds, and superior major molecular response outcomes for patients with CML compared with published literature. As a result, this model has produced the gold standard in managing patients receiving oral chemotherapy.

National trends in prescription drug expenditures and projections for 2018

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2018 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2017 were obtained from the IQVIA (formerly QuintilesIMS) National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2018 were also reviewed. Expenditure projections for 2018 for nonfederal hospitals, clinics, and overall (all sectors) were made based on a combination of quantitative analyses and expert opinion.

RESULTS

Total U.S. prescription sales in the 2017 calendar year were $455.9 billion, a 1.7% increase compared with 2016. The top drug based on expenditures was adalimumab ($17.1 billion), followed by insulin glargine and etanercept. Prescription expenditures in nonfederal hospitals totaled $34.2 billion, a 0.7% decrease in 2017 compared with 2016. Expenditures in clinics increased 10.9%, to a total of $70.8 billion. The decrease in spending in nonfederal hospitals was driven by lower utilization. The top 25 drugs by expenditures in nonfederal hospitals and clinics were dominated by specialty drugs.

CONCLUSION

We project a 3.0-5.0% increase in total drug expenditures across all settings, a 11.0-13.0% increase in clinics, and a 0.0-2.0% increase in hospital drug spending in 2018. Health-system pharmacy leaders should carefully examine their own local drug utilization patterns to determine their own organization's anticipated spending in 2018.

The Opportunity for Telehealth to Support Neurological Healthcare

Neurological conditions affect one-third of Americans and are some of the most prevalent health issues in the country. Many sufferers have difficulty accessing treatment, however, advances in technology may be able to support availability, affordability, and convenience of care through telehealth services. This review outlines the current state of telemedicine in neurological healthcare, highlighting evidence-based research and use cases for digital services. Details on expenses associated with managing certain well-known conditions are included to shed light on the financial burden of disease and how telehealth can contribute to cost savings for patients and providers. Finally, a discussion of current telehealth legislature gives additional perspective on regulatory dynamics experienced by different stakeholders in the field. Research supports telemedicine as a solution to enhance current care models given its many benefits, including efficient and clinically useful service delivery. This movement has the opportunity to help billions of individuals globally by acting as a mechanism to provide impactful and scalable neurological healthcare.

Treatment with proton pump inhibitors is associated with increased mortality in patients with pyogenic liver abscess

BACKGROUND

Proton pump inhibitors (PPI) are often used in patients with gastro-esophageal reflux and peptic ulcer disease. A higher risk for infectious diseases and for pyogenic liver abscess has been reported in patients with prolonged PPI intake. Although many patients have ongoing PPI treatment after diagnosis of liver abscess, there are no data available that focus on the prognostic impact of PPI treatment in these patients.

AIM

To analyse the effect of PPI treatment on mortality in patients with pyogenic liver abscesses.

METHODS

Between January 2005 and March 2017, one hundred and eighty-one patients with pyogenic liver abscess were retrospectively included in this analysis. Medical records including PPI treatment, microbiological and imaging data were reviewed. The primary endpoint was index mortality and predictive factors were analysed using uni- and multivariate logistic regression models.

RESULTS

One hundred patients with pyogenic liver abscess (55.2%) were treated with PPI compared to 81 patients (44.8%) without PPI treatment. In both patient cohorts, enterococcus spp. and streptococcus of the anginous group were the most common pathogens identified. Patients with PPI treatment had significantly higher index mortality compared to patients without PPI treatment (30.0% vs 11.1%, P = 0.003). After adjusting for comorbidities PPI remained an independent predictive factor with an OR of 2.56 (1.01-6.46, P = 0.036).

CONCLUSIONS

PPI treatment is associated with higher index mortality in patients with pyogenic liver abscess. Therefore, critical evaluation of the indication for PPI treatment is particularly important in patients at high risk for pyogenic liver abscess.

Alzheimer Disease and Related Disorders and Out-of-Pocket Health Care Spending and Burden Among Elderly Medicare Beneficiaries

OBJECTIVE

To estimate the excess burden of out-of-pocket health care spending associated with Alzheimer disease and related disorders (ADRD) among older individuals (age 65 y and older).

METHODS

We adopted a retrospective, cross-sectional study design with data from 2012 Medicare Current Beneficiary Survey. The study sample comprised of elderly community-dwelling individuals who had positive total health care expenditures, and enrolled in Medicare throughout the calendar year (462 with ADRD, and 7160 without ADRD). We estimated the per-capita total annual out-of-pocket spending on health care and out-of-pocket spending by service type: inpatient, outpatient, home health, prescription drugs, and other services. We measured out-of-pocket spending burden by calculating the percentage of income spent on health care and defined high out-of-pocket spending burden as having this percentage above 10%. Multivariable analyses included ordinary least squares regressions and logistic regressions and these analyses adjusted for predisposing, enabling, need, personal health care practices and external environment characteristics.

RESULTS

The average annual per-capita out-of-pocket health care spending was greater among individuals with ADRD compared with those without ADRD ($3285 vs. $1895); home health and prescription drugs accounted for 52% of total out-of-pocket spending among individuals with ADRD and 34% among individuals without ADRD. Elderly individuals with ADRD were more likely to have high out-of-pocket spending burden (adjusted odds ratio, 1.49; 95% confidence interval, 1.13-1.97) compared with those without ADRD.

CONCLUSION

ADRD is associated with excess out-of-pocket health care spending, primarily driven by prescription drugs and home health care use.

Following the Biosimilar Breadcrumbs: When Health Systems and Manufacturers Approach Forks in the Road

Over 2 years have passed since the first biosimilar was approved for use in the United States. Despite a relatively slow start, biosimilar activity has significantly increased in recent months. Biologics are the most expensive drug category in the United States, costing patients hundreds or even thousands of dollars per year. Biosimilars have the potential to significantly decrease cost of care, increase access, and improve patient outcomes. In order to realize the potential savings, biosimilar manufacturers, health care providers, and payers must develop strategies to navigate the challenging health care environment and understand where and how biosimilars bring the most value to patients. Trends in biosimilar uptake within health systems have demonstrated the need for manufacturers to deploy a robust product strategy before and after launch. In order to gain high-level insight from health system experiences with the first infliximab biosimilar approved in the United States, a questionnaire was distributed to pharmacy representatives from health systems during March and April 2017. Responses from more than 50 health systems across the country revealed that the key barriers and challenges faced with biosimilar uptake include payers and reimbursement, interchangeability, provider preference, and cost. This article explores health system experiences with biosimilars thus far and describes real-world implementation strategies. In addition, insights into manufacturer considerations are highlighted with regard to financial, clinical, and operational decisions.

DISCLOSURES

The author received no outside funding support and has nothing to disclose.