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Alping P, Neovius M, Piehl F, Frisell T. Real-World Healthcare Cost Savings and Reduced Relapse Rate with Off-Label Rituximab versus Disease-Modifying Treatments Approved for Relapsing-Remitting Multiple Sclerosis: A Nationwide Cost-Effectiveness Study. Ann Neurol 2024; 95:1099-1111. [PMID: 38529711 DOI: 10.1002/ana.26914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE Although off-label use of rituximab is a common alternative to disease-modifying therapies (DMTs) approved for multiple sclerosis (MS) in several countries, the impact of this on treatment cost-effectiveness is not well known. METHODS We evaluated the relative cost-effectiveness of rituximab and MS-approved DMTs in a register-based cohort study of Swedish residents with relapsing-remitting MS, aged 18-65 years, starting treatment with rituximab, natalizumab, fingolimod, or dimethyl fumarate between January 2010 and July 2016, and followed through July 2021 (n = 5,924). By linking the population-based Swedish MS register to several Swedish health care and demographic registers, we estimated health care costs in relation to number of relapses, over 5 years from treatment start. Differences between treatments were estimated in inverse probability of treatment-weighted regression models, adjusting for a broad range of potential confounders covering demographics, medical history, and MS-related clinical characteristics. RESULTS Off-label rituximab was associated with both lower total health care costs (mean cost savings ranged $35,000-$66,000 vs. each approved DMT), and fewer relapses (mean number of prevented relapses ranged 0.12-0.22), per started therapy over 5 years. Results were robust to variations in discounting and pricing of health care visits, with the main driver of cost-savings being the price of the index drug itself. INTERPRETATION The cost-effectiveness of rituximab dominated the MS-approved alternatives. Off-label, low-dose rituximab should be considered for persons with MS and could reduce barriers to treatment, especially in resource-limited settings. ANN NEUROL 2024;95:1099-1111.
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Affiliation(s)
- Peter Alping
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Martin Neovius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Abstract
This study examines insurer coverage of ivermectin prescriptions for COVID-19 in the US.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
| | - Rena M. Conti
- Department of Markets, Public Policy, and Law, Questrom School of Business, Boston University, Boston, Massachusetts
| | - Nora V. Becker
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
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Herbrand AK, Schmitt AM, Briel M, Ewald H, Goldkuhle M, Diem S, Hoogkamer A, Joerger M, Moffa G, Novak U, Hemkens LG, Kasenda B. Association of Supporting Trial Evidence and Reimbursement for Off-Label Use of Cancer Drugs. JAMA Netw Open 2021; 4:e210380. [PMID: 33651108 PMCID: PMC7926292 DOI: 10.1001/jamanetworkopen.2021.0380] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE In many health systems, access to off-label drug use is controlled through reimbursement restrictions by health insurers, especially for expensive cancer drugs. OBJECTIVE To determine whether evidence from randomized clinical trials is associated with reimbursement decisions for requested off-label use of anticancer drugs in the Swiss health system. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used reimbursement requests from routinely collected health records of 5809 patients with drug treatment for cancer between January 2015 and July 2018 in 3 major cancer centers, covering cancer care of approximately 5% of the Swiss population, to identify off-label drug use. For each off-label use indication with 3 or more requests, randomized clinical trial evidence on treatment benefits was systematically identified for overall survival (OS) or progression-free survival (PFS). Data were analyzed from August 2018 to December 2020. EXPOSURES Available randomized clinical trial evidence on benefits for OS or PFS for requested off-label use indications. MAIN OUTCOMES AND MEASURES The main outcome was the association between evidence for treatment benefit (expressed as improved OS or PFS) and reimbursement in multivariable regression models. RESULTS Among 3046 patients with cancer, 695 off-label use reimbursement requests in 303 different indications were made for 598 patients (median [interquartile range] age, 64 [53-73] years; 420 [60%] men). Off-label use was intended as first-line treatment in 311 requests (45%). Reimbursement was accepted in 446 requests (64%). For 71 indications, including 431 requests for 376 patients, there were 3 or more requests. Of these, 246 requests (57%) had no supporting evidence for OS or PFS benefit. Reimbursement was granted in 162 of 246 requests without supporting evidence (66%). Of 117 requests supported by OS benefit, 79 (67%) were reimbursed, and of 68 requests supported by PFS benefit alone, 54 (79%) were reimbursed. Evidence of OS benefit from randomized clinical trials was not associated with a higher chance of reimbursement (odds ratio, 0.76, 95% CI, 0.45-1.27). CONCLUSIONS AND RELEVANCE These findings suggest that in a health care system enabling access to off-label use, it was frequently intended as a first-line treatment in cancer care. Availability of randomized clinical trial evidence showing survival benefit was not associated with reimbursement decisions for off-label anticancer drug treatment in Switzerland. A transparent process with criteria considering clinical evidence is needed for evidence-based reimbursement decisions to ensure fair access to cancer treatments.
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Affiliation(s)
- Amanda Katherina Herbrand
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Internal Medicine, St Claraspital, Basel, Switzerland
| | - Andreas M. Schmitt
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- University Medical Library, University of Basel, Basel, Switzerland
| | - Marius Goldkuhle
- Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Stefan Diem
- Department of Oncology and Hematology, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Oncology and Hematology, Spital Grabs, Grabs, Switzerland
| | - Anouk Hoogkamer
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Markus Joerger
- Department of Oncology and Hematology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Giusi Moffa
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Bern University Hospital, Bern, Switzerland
| | - Lars G. Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Meta-Research Innovation Center Berlin (METRICS-B), Berlin Institute of Health, Berlin, Germany
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
| | - Benjamin Kasenda
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
- Research and Development, iOMEDICO, Freiburg, Germany
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Watkins JB, Sullivan SD, Sampsel E, Fullerton DS“P, Graff JS, Fry RN, Lee J, Tam IM, Avey SG. Evolution of the AMCP Format for Formulary Submissions. J Manag Care Spec Pharm 2020; 26:696-700. [PMID: 32463780 PMCID: PMC10391300 DOI: 10.18553/jmcp.2020.26.6.696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES No funding was required for this project. The authors are or have been members of the Format Executive Committee.
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Affiliation(s)
- John B. Watkins
- Residency Program Director, Premera Blue Cross, Mountlake Terrace, Washington, and Affiliate Professor of Pharmacy, University of Washington, Seattle
| | - Sean D. Sullivan
- Dean, School of Pharmacy and Professor of Pharmacy, Health Services and Medicine, University of Washington, Seattle
| | - Elizabeth Sampsel
- Senior Director, Payer, Provider and Partner Alliances, Xcenda, Palm Harbor, Florida
| | | | - Jennifer S. Graff
- Vice President Comparative Effectiveness Research, National Pharmaceutical Council, Washington, DC
| | - Richard N. Fry
- Former FMCP Director of Programs, Leland, North Carolina
| | - Jeff Lee
- Associate Dean for Academic Affairs, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Iris M. Tam
- Senior Director, HEOR, Patient Access & Value, Coeus Consulting Group, Daly City, California
| | - Steven G. Avey
- Executive Director Emeritus, AMCP Foundation, Alexandria, Virginia
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Cannon E. Managed care opportunities and approaches to supporting appropriate selection of treatment for sight preservation. Am J Manag Care 2019; 25:S182-S187. [PMID: 31419089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
When evaluating the impact of vision-destroying diseases, pharmacologic therapies represent a significant cost to patients, insurance providers, and society. Currently, up to 11 million people in the United States have some form of age-related macular degeneration (AMD), which is one of the leading causes of vision loss in older Americans. Ophthalmologists have administered more than 6 million intravitreal injections of aflibercept, bevacizumab, pegaptanib, and ranibizumab last year. Comprehensive assessment requires managed care administrators and clinicians to understand the direct and indirect costs of vision loss as well as the comparative safety and efficacy profiles for each agent. In AMD, it is critical to understand the established and emerging treatment patterns.
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Affiliation(s)
- Eric Cannon
- Vice President, Pharmacy Benefits, SelectHealth, Murray, UT.
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Cauchi R. State Remedies For Costly Prescription Drugs. NCSL Legisbrief 2018; 26:1-2. [PMID: 30199170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
(1) At least 74.7 million Americans use three or more prescription drugs in a 30-day period. (2) Eighty percent of the U.S. public views prescription drug costs as "unreasonable," while 17 percent say “reasonable,” according to a recent poll. (3) An influenza drug has a cash price of $100, but a patient with insurance may pay $125 because of a “gag clause” that restricts pharmacists from disclosing price options.
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van Asten F, Michels CTJ, Hoyng CB, van der Wilt GJ, Klevering BJ, Rovers MM, Grutters JPC. The cost-effectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-A cost-effectiveness analysis from a societal perspective. PLoS One 2018; 13:e0197670. [PMID: 29772018 PMCID: PMC5957378 DOI: 10.1371/journal.pone.0197670] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The discussion on the use of bevacizumab is still ongoing and often doctors are deterred from using bevacizumab due to legal or political issues. Bevacizumab is an effective, safe and inexpensive treatment option for neovascular age-related macular degeneration (AMD), albeit unregistered for the disease. Therefore, in some countries ophthalmologists use the equally effective but expensive drugs ranibizumab and aflibercept. We describe the economic consequences of this dilemma surrounding AMD treatment from a societal perspective. METHODS We modelled cost-effectiveness of treatment with ranibizumab (as-needed), aflibercept (bimonthly) and bevacizumab (as-needed). Effectiveness was estimated by systematic review and meta-analysis. The drug with the most favourable cost-effectiveness profile compared to bevacizumab was used for threshold analyses. First, we determined how much we overspend per injection. Second, we calculated the required effectiveness to justify the current price and the reasonable price for a drug leading to optimal vision. Finally, we estimated how much Europe overspends if bevacizumab is not first choice. RESULTS Bevacizumab treatment costs €27,087 per year, about €4,000 less than aflibercept and €6,000 less than ranibizumab. With similar effectiveness for all drugs as shown by meta-analysis, bevacizumab was the most cost-effective. Aflibercept was chosen for threshold analyses. Aflibercept costs €943 per injection, but we determined that the maximum price to be cost-effective is €533. Alternatively, at its current price, aflibercept should yield about twice the visual gain. Even when optimal vision can be achieved, the maximum price for any treatment is €37,453 per year. Most importantly, Europe overspends €335 million yearly on AMD treatment when choosing aflibercept over bevacizumab. CONCLUSION Bevacizumab is the most cost-effective treatment for AMD, yet is not the standard of care across Europe. The registered drugs ranibizumab and aflibercept lead to large overspending without additional health benefits. Health authorities should consider taking steps to implement bevacizumab into clinical practice as first choice.
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Affiliation(s)
- Freekje van Asten
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Charlotte T. J. Michels
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carel B. Hoyng
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Jan van der Wilt
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B. Jeroen Klevering
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M. Rovers
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P. C. Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Bro T. [An eye for an eye? Lack of consensus in off-label use of medications leads to major regional differences in medical costs for the treatment of wet AMD in Sweden]. Lakartidningen 2017; 114:ESF6. [PMID: 29292948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
An eye for an eye? Lack of consensus in off-label use of medications leads to major regional differences in medical costs for the treatment of wet AMD in Sweden. The three ocular VEGF inhibitors available in Sweden have similar efficacy and safety. Only two are however registered for wet AMD. The remaining, Avastin, is developed for oncological indications, but used for wet AMD in many parts of the world. Major regional differences exist in the use of Avastin in Sweden. In the three largest cities, it is not used at all. As a consequence, the yearly drug cost for a patient with wet AMD differs from 2 000 to 44 000 SEK. As this difference is not compatible with the Swedish law of "care on equal terms", increased efforts should be made to obtain a national consensus.
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Affiliation(s)
- Tomas Bro
- Region Jönköpings län - Ögonmottagningen Höglandssjukhuset Eksjö, Sweden Region Jönköpings län - Ögonmottagningen Höglandssjukhuset Eksjö, Sweden
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10
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Dyer O. Novo Nordisk pays $58.7m to settle claims of mis-selling liraglutide. BMJ 2017; 358:j4214. [PMID: 28887314 DOI: 10.1136/bmj.j4214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Zhang H, Zaric GS. Using price-volume agreements to manage pharmaceutical leakage and off-label promotion. Eur J Health Econ 2015; 16:747-61. [PMID: 25193525 DOI: 10.1007/s10198-014-0626-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/05/2014] [Indexed: 05/05/2023]
Abstract
Unapproved or "off-label" uses of prescription drugs are quite common. The extent of this use may be influenced by the promotional efforts of manufacturers. This paper investigates how a manufacturer makes promotional decisions in the presence of a price-volume agreement. We developed an optimization model in which the manufacturer maximizes its expected profit by choosing the level of marketing effort to promote uses for different indications. We considered several ways a volume threshold is determined. We also compared models in which off-label uses are reimbursed and those in which they are forbidden to illustrate the impact of off-label promotion on the optimal decisions and on the decision maker's performance. We found that the payer chooses a threshold which may be the same as the manufacturer's optimal decision. We also found that the manufacturer not only considers the promotional cost in promoting off-label uses but also considers the health benefit of off-label uses. In some situations, using a price-volume agreement to control leakage may be a better idea than simply preventing leakage without using the agreement, from a social welfare perspective.
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Affiliation(s)
- Hui Zhang
- Faculty of Business Administration, Lakehead University, Thunder Bay, ON, P7B 5E1, Canada,
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Affiliation(s)
- Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, Oxford OX2 6GG, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK
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Kordus K, Spiewak R. [Physician versus 'off-label" ordinance]. Przegl Lek 2015; 72:38-41. [PMID: 26076577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Polish physicians are obliged by legislation to prescribe drugs authorized for the sale in the Republic of Poland, based on registration documentation, including the Summaries of Product Characteristics (SPC). So called 'off label' treatment occurs in case of the conflict between prescription and information contained in the SPC, which may be considered as a 'medical experiment'. In case of adverse drug reactions, such classification excludes the responsibility of the marketing authorization holders, and damages are not covered by obligatory third party insurance, which can pose financial and legal consequences to the doctor. Deviations from SPC-compliant prescription may include a different way of drug administration, drug administration compliant with the indications yet in patients for whom there is no specified drug dosage, or in case of an indication not contained in the SPC. Medicinal products with equivalent active component, form and dose can have different registration indications in the SPC, and the actively promoted dispensation of less expensive substitutes by the pharmacists may, against doctor's will, result in the use that is non-compliant with registration of the substitute drug. Pharmacotherapy of 'orphan diseases', for which there are no registered medicinal products, also becomes an essential issue as it forces doctors into 'off-label' prescriptions. Moreover, the reimbursement of drugs in most cases is limited to medicinal products that are prescribed according to the registration indications. The pleas by medical professionals to make ordination and reimbursement of drugs depend on active pharmaceutical ingredient and evidence of efficacy, as well as to introduce Evidence Based Medicine (EBM) standards for the treatment of diseases, did not receive proper attention from the governing bodies. Therefore, a fundamental question remains unanswered as to what should be the principal gauge for physicians' therapeutic decision: the ethics, conscience, recent scientific evidence or legal and administrative regulations?
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Affiliation(s)
- Surrey M Walton
- Department of Pharmacy Systems, Outcomes, and Policy, UIC, 833 S. Wood Street (M/C 871), Chicago, IL, 60612, USA,
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Formoso G, Marata AM, Magrini N, Bero L. A clearer view of evidence in treating macular degeneration: off-label policies and independent research. Cochrane Database Syst Rev 2014; 2014:ED000090. [PMID: 25228121 PMCID: PMC10845851 DOI: 10.1002/14651858.ed000090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Giulio Formoso
- Drug Evaluation Area, Regional Agency for Health and Social Care, Bologna, Italy
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17
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Nau JY. [Addictions, alcoholism and baclofen: latest French news]. Rev Med Suisse 2014; 10:1366-1367. [PMID: 25051604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Zimmerman GW. [Active contract physicians are liable for recourse claims of "passive" contract physicians]. MMW Fortschr Med 2013; 155:13. [PMID: 24340369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Lee J. PhRMA sues on 340B orphans. Mod Healthc 2013; 43:17. [PMID: 24340726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Silverman E. Pfizer versus Kaiser: insurers want their day in court. BMJ 2013; 346:f3738. [PMID: 23760967 DOI: 10.1136/bmj.f3738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Conti RM, Bernstein AC, Villaflor VM, Schilsky RL, Rosenthal MB, Bach PB. Prevalence of off-label use and spending in 2010 among patent-protected chemotherapies in a population-based cohort of medical oncologists. J Clin Oncol 2013; 31:1134-9. [PMID: 23423747 PMCID: PMC3595423 DOI: 10.1200/jco.2012.42.7252] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The prevalence of off-label anticancer drug use is not well characterized. The extent of off-label use is a policy concern because the clinical benefits of such use to patients may not outweigh costs or adverse health outcomes. METHODS Prescribing data from IntrinsiQ Intellidose data systems, a pharmacy software provider maintaining a population-based cohort database of medical oncologists, was analyzed. Use of the most commonly prescribed anticancer drugs ("chemotherapies") that were patent protected and administered intravenously to patients in 2010 was examined. Use was classified as "on-label" if the cancer site, stage, and therapy line met the US Food and Drug Administration (FDA)-approved indication. All other use was "off-label." Off-label use was divided by whether it conformed to National Comprehensive Care Network (NCCN) Compendium recommendations, a basis of insurer coverage policies. IMS Health National Sales Perspectives was used to estimate national spending by use category. RESULTS Ten chemotherapies met inclusion criteria. On-label use amounted to 70%, and off-label use amounted to 30%. Fourteen percent of use conformed to an NCCN-supported off-label indication, and 10% of off-label use was associated with an FDA-approved cancer site, but an NCCN-unsupported cancer stage and/or line of therapy. Total national spending on these chemotherapies amounted to $12 billion (B; $7.3B on-label, $2B off-label and NCCN supported; $2.5B off-label and NCCN unsupported). CONCLUSION Commonly used, novel chemotherapies are more often used on-label than off-label in contemporary practice. Off-label use is composed of a roughly equal mix of chemotherapy applied in clinical settings supported by the NCCN and those that are not.
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Affiliation(s)
- Rena M Conti
- Department of Pediatrics, Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA.
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22
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Neubauer AS, Kernt M. [Age-related visual loss]. MMW Fortschr Med 2013; 155:36-37. [PMID: 23573743 DOI: 10.1007/s15006-013-0107-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Telekes A. [Letters to the Editors. Reflections about oncology. II. The reorganization of oncology -- solution or expansion of the problems?]. Orv Hetil 2013; 154:76-9. [PMID: 23291207 DOI: 10.1556/oh.2013.2m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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de Souza JA, Polite B, Perkins M, Meropol NJ, Ratain MJ, Newcomer LN, Alexander GC. Unsupported off-label chemotherapy in metastatic colon cancer. BMC Health Serv Res 2012; 12:481. [PMID: 23272659 PMCID: PMC3544564 DOI: 10.1186/1472-6963-12-481] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 12/26/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Newer systemic therapies have the potential to decrease morbidity and mortality from metastatic colorectal cancer, yet such therapies are costly and have side effects. Little is known about their non-evidence-based use. METHODS We conducted a retrospective cohort study using commercial insurance claims from UnitedHealthcare, and identified incident cases of metastatic colon cancer (mCC) from July 2007 through April 2010. We evaluated the use of three regimens with recommendations against their use in the National Comprehensive Cancer Center Network Guidelines, a commonly used standard of care: 1) bevacizumab beyond progression; 2) single agent capecitabine as a salvage therapy after failure on a fluoropyridimidine-containing regimen; 3) panitumumab or cetuximab after progression on a prior epidermal growth factor receptor antibody. We performed sensitivity analyses of key assumptions regarding cohort selection. Costs from a payer perspective were estimated using the average sales price for the entire duration and based on the number of claims. RESULTS A total of 7642 patients with incident colon cancer were identified, of which 1041 (14%) had mCC. Of those, 139 (13%) potentially received at least one of the three unsupported off-label (UOL) therapies; capecitabine was administered to 121 patients and 49 (40%) likely received it outside of clinical guidelines, at an estimated cost of $718,000 for 218 claims. Thirty-eight patients received panitumumab and six patients (16%) received it after being on cetuximab at least two months, at an estimated cost of $69,500 for 19 claims. Bevacizumab was administered to 884 patients. Of those, 90 (10%) patients received it outside of clinical guidelines, at an estimated costs of $1.34 million for 636 claims. CONCLUSIONS In a large privately insured mCC cohort, a substantial number of patients potentially received UOL treatment. The economic costs and treatment toxicities of these therapies warrant increased efforts to stem their use in settings lacking sufficient scientific evidence.
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Affiliation(s)
- Jonas A de Souza
- Section of Hematology/Oncology, The University of Chicago Medicine, Chicago, IL, USA
- Comprehensive Cancer Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Blase Polite
- Section of Hematology/Oncology, The University of Chicago Medicine, Chicago, IL, USA
- Comprehensive Cancer Center, The University of Chicago Medicine, Chicago, IL, USA
- Center for Interdisciplinary Health Disparities Research, The University of Chicago Medicine, 5841 South Maryland Avenue, MC 2115, Chicago, IL, 60637-1470, USA
| | | | - Neal J Meropol
- Division of Hematology and Oncology, University Hospitals Case Medical Center Seidman Cancer Center, Case Western Reserve University, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, The University of Chicago Medicine, Chicago, IL, USA
- Comprehensive Cancer Center, The University of Chicago Medicine, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics and Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
| | | | - G Caleb Alexander
- Section of General Medicine and Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
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Mehr SR. The complexity of covering off-label use for a multitude of oncology regimens. Am J Manag Care 2012; 18:SP242-SP247. [PMID: 23301714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Abstract
The effects of orphan drug policies raise serious concerns among payer organizations and lead to often-tragic disappointment for patients who are denied much anticipated drug reimbursements. We evaluate the effects of orphan drug policies on the basis of this concern for real accessibility to drugs. We highlight two unforeseen effects of orphan drug policies: 1) they provide unique business opportunities for manufacturers and 2) drugs approved through these policies are often inaccessible because of their high price. We identify six causes of this emergence of effects. The first four are the direct result of incentives included in orphan drug policies. The fifth cause is the "off-label" use of orphan drugs. These emergent effects have several implications: 1) they raise doubts about the equity of access to drugs, 2) they highlight the limitations of the cohort paradigm in medicine, and c) they force third-party payers to make drugs accessible even when the prices of drugs are believed to be disproportionate to the clinical effects obtained.
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Affiliation(s)
- André Côté
- Faculté des sciences de l'administration, Université Laval, Québec, QC, Canada.
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Abstract
The assessment of off-label medications is one of the most common reasons for assessment of drugs for individual patients in the German medical services. Tension is not uncommon because of great expectations of patients and doctors on the one hand and the requirements of the law on the other. They often do not match. Even if there is a medically justified off-label use the road to drug approval is principally via the authorities with tested efficacy and safety in order not to deprive the patient of the protection of the Pharmaceuticals Act. The jurisdiction has approved criteria for reimbursement by the statutory health insurance only in clearly defined exception and one requirement is that there are no alternative forms of treatment. For serious diseases this is based on the evidence of drug approval; however, for immediately life-threatening situations a very low evidence level is sufficient.
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Affiliation(s)
- L Grell
- Medizinischer Dienst der Krankenversicherung Westfalen-Lippe, Paderborn, Deutschland.
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Kesselheim AS, Myers JA, Solomon DH, Winkelmayer WC, Levin R, Avorn J. The prevalence and cost of unapproved uses of top-selling orphan drugs. PLoS One 2012; 7:e31894. [PMID: 22363762 PMCID: PMC3283698 DOI: 10.1371/journal.pone.0031894] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 01/18/2012] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION The Orphan Drug Act encourages drug development for rare conditions. However, some orphan drugs become top sellers for unclear reasons. We sought to evaluate the extent and cost of approved and unapproved uses of orphan drugs with the highest unit sales. METHODS We assessed prescription patterns for four top-selling orphan drugs: lidocaine patch (Lidoderm) approved for post-herpetic neuralgia, modafinil (Provigil) approved for narcolepsy, cinacalcet (Sensipar) approved for hypercalcemia of parathyroid carcinoma, and imatinib (Gleevec) approved for chronic myelogenous leukemia and gastrointestinal stromal tumor. We pooled patient-specific diagnosis and prescription data from two large US state pharmaceutical benefit programs for the elderly. We analyzed the number of new and total patients using each drug and patterns of reimbursement for approved and unapproved uses. For lidocaine patch, we subcategorized approved prescriptions into two subtypes of unapproved uses: neuropathic pain, for which some evidence of efficacy exists, and non-neuropathic pain. RESULTS We found that prescriptions for lidocaine patch, modafinil, and cinacalcet associated with non-orphan diagnoses rose at substantially higher rates (average monthly increases in number of patients of 14.6, 1.45, and 1.58) than prescriptions associated with their orphan diagnoses (3.12, 0.24, and 0.03, respectively (p<0.001 for all)). By contrast, for imatinib, approved uses increased significantly over off-label (0.97 vs. 0.47 patients, p<0.001). Spending on off-label uses was highest for lidocaine patch and modafinil (>75%). Increases in lidocaine patch use for non-neuropathic pain far exceeded neuropathic pain (10.2 vs. 3.6 patients, p<0.001). DISCUSSION In our sample, three of four top-selling orphan drugs were used more commonly for non-orphan indications. These orphan drugs treated common clinical symptoms (pain and fatigue) or laboratory abnormalities. We should continue to monitor orphan drug use after approval to identify products that come to be widely used for non-FDA approved indications, particularly those without adequate evidence of efficacy.
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Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America.
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Hammerman A, Lipschitz Y, Pliskin J, Greenberg D. [Public financing for off-label use of drugs]. Harefuah 2011; 150:163-204. [PMID: 22164947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Off-label use of drugs is common in all areas of medicine, but is specifically prevalent in pediatrics, oncology and in treating rare diseases. Such use may benefit patients, but on the other hand, there is concern about the safety aspects of these treatments. Besides the legal, ethical and safety issues associated with off-label use, arises the issue of whether such prescribing should be reimbursed by public funds. According to Ministry of Health (MoH) guidelines, the committee in charge of updating the National List of Health Services (NLHS) did not discuss, from its inception and until its deliberations at the end of 2008, off-label indications. This policy was to protect the Israeli pharmaceutical registration mechanism, prevent registration bypass mechanisms and not grant use of public funds for reimbursing treatments for which there were insufficient evidence on safety and efficacy. The patients most affected by this policy were the ones that could not benefit from a drug that was not in the NLHS for their medical condition and had to pay for it out of pocket. Occasionally, health plans agreed to subsidize critically needed off-label treatments, although they did not receive public funding for off-label indications. In this article we review the problems associated with off-label prescribing, the reasons why the MoH changed its policy at the beginning of 2009 to permit, in very special circumstances, reimbursement of off-label treatment. We also provide a brief summary of off-label policies in a few western countries.
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Affiliation(s)
- Ariel Hammerman
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer Sheba.
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Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995-2008. Pharmacoepidemiol Drug Saf 2011; 20:177-84. [PMID: 21254289 PMCID: PMC3069498 DOI: 10.1002/pds.2082] [Citation(s) in RCA: 296] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 10/22/2010] [Accepted: 11/08/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate patterns of antipsychotic use. DESIGN, SETTING, AND MEASUREMENTS: We used nationally representative data from the IMS Health National Disease and Therapeutic Index to describe outpatient antipsychotic use. The primary outcome was the volume of visits where antipsychotics were used for specific indications (treatment visits). We also quantified use without U.S. Food and Drug Administration approval (off-label use) and off-label use with compendium data suggesting an uncertain evidence base. RESULTS Antipsychotic use increased from 6.2 million (M) treatment visits (95% CI, 5.4-7.0) in 1995 to 16.7 M visits (15.5-18.2) in 2006, then declined to 14.3 M visits (13.0-15.6) by 2008. A shift occurred from typical agents in 1995 (84% of all antipsychotic visits) to atypical agents by 2008 (93%). As they declined, typical medications shifted toward use in schizophrenia (30% in 1995 to 48% 2008). In contrast, use of atypical agents expanded for bipolar affective disorder (10 to 34%), remained stable for depression (12 to 14%), and declined for schizophrenia (56 to 23%). Overall, antipsychotic use for indications without FDA approval increased from 4.4 M visits in 1995 to 9.0 M in 2008. The estimated cost associated with off-label use in 2008 was US$6.0 billion. CONCLUSIONS Atypical use has grown far beyond substitution for the now infrequently used typical agents. Antipsychotics are increasingly used for conditions where FDA approval and associated clinical evidence is less certain. Despite the value of innovation, the benefits of widening atypical antipsychotic use should be weighed against their cost, regulatory status, and incomplete nature of available evidence.
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Affiliation(s)
- G C Alexander
- Department of Medicine, University of Chicago Hospitals, Chicago, Illinois, USA.
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Targeting drug companies' bottom line. Prescrire Int 2011; 20:25. [PMID: 21462792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Martin CM. Off-label use of medications: innovative prescribing or risky business? Consult Pharm 2010; 25:806-814. [PMID: 21172761 DOI: 10.4140/tcp.n.2010.806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Off-label use of medication is common and can lead to innovations in the use of medicine to treat patients in unconventional ways. However, issues of increased health care costs, decreased reimbursement, and lack of clinical data to support off-label use, are concerns of practitioners and patients alike. By using their knowledge of medications and carefully examining the existing research, pharmacists can aid prescribers in appropriate off-label medication use.
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Joshi AD, Patel DA, Holdford DA. Media coverage of off-label promotion: a content analysis of US newspapers. Res Social Adm Pharm 2010; 7:257-71. [PMID: 21272550 DOI: 10.1016/j.sapharm.2010.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 06/21/2010] [Accepted: 06/22/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Promotion of drugs for off-label use is newsworthy, because it is an illegal but all too common strategy used by pharmaceutical companies. The print media are an important source of information about coverage of off-label promotion of drugs and devices and can influence public perceptions of the practice. OBJECTIVES Print media coverage of off-label promotion during the years 1990-2008 were described and quantified. The primary themes and general tones relating to off-label promotion articles were evaluated. General concerns associated with off-label promotion and complaints about specific brand name drugs were also identified. METHODS Content analyses of the top 6 US newspapers were conducted over the period of 1990-2008 to analyze the media coverage given to off-label promotion of drugs and devices. Headlines and full text of articles were analyzed for primary themes and tones of the coverage. Intercoder reliability tests were performed on all the study variables. RESULTS One hundred and one articles were identified meeting the study inclusion criteria. Coverage varied by newspaper. The Wall Street Journal had the most coverage on the topic (45%), and USA Today and Chicago Tribune had the least coverage (5%). Overall, most of the stories sampled were deemed to have a negative tone in coverage (77%), focusing mainly on lawsuits against drug companies for promoting their drugs for off-label uses. Pfizer's Neurontin(®) (Pfizer Inc., New York, NY 10017, USA) and Johnson & Johnson's Retin-A(®) (Orthoneutrogena, Los Angeles, CA 90045, USA) received the most media attention. CONCLUSION The news media helps shape public understanding of promotional practices of pharmaceutical companies and their potential benefits and harms. This study suggests that print media coverage is generally negative about off-label promotion, focusing on legal actions taken against drug companies and the negative consequences of such promotional practices.
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Affiliation(s)
- Avani D Joshi
- Virginia Commonwealth University, School of Pharmacy, McGuire Hall, Richmond, USA
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Abstract
Most drugs prescribed for patients as part of their NHS treatment are licensed medicinal products. However, there are rare occasions when a patient needs a formulation or strength that is not available as a licensed form, or needs to avoid ingredients that provoke allergy. To address such needs, many specially prepared products are produced by specialist manufacturing units. These so-called 'specials', unlike licensed medicines, are not assessed for safety or efficacy by a regulatory body.¹ Prescribers are often unaware of the costs of specials. Here we explore some of the issues associated with specials in primary care and whether their use represents good value for money.
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Affiliation(s)
- Melanie Newman
- Bureau of Investigative Journalism, City University, London EC1V7HD, UK.
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Patel H, Toe DC, Burke S, Rasu RS. Anticonvulsant use after formulary status change for brand-name second-generation anticonvulsants. Am J Manag Care 2010; 16:e197-e204. [PMID: 20690786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Anticonvulsant medications are commonly used for off-label indications. However, managed care organizations can restrict utilization of medication to indicated uses only. OBJECTIVE To evaluate the pattern of off-label use of second-generation anticonvulsants after implementing a formulary change. METHODS We did a retrospective analysis of an administrative pharmacy claims database for a managed care plan with more than 1 million members continuously enrolled during 2004-2005. The study evaluated off-label use and explored pharmacy utilization patterns (by physician specialty, region, plan type, age, sex, copayment) across the study population following the formulary change. RESULTS A total of 10,185 patients had at least 1 pharmacy claim (total of 137,638 claims) for a second-generation anticonvulsant during the study period. Most members were female (68%), and 4.9% were <18 years old. A total of 3986 of 4698 patients (84.8%) and 4600 of 5487 patients (83.8%) had anticonvulsants prescribed for off-label use in 2004 and 2005, respectively (P = .162). The off-label usage pattern varied for individual anticonvulsants in 2004 and 2005 (P <.050), which may have been because of the change to nonpreferred coverage. Primary care physicians accounted for 41.3% of the prescribing of second-generation anticonvulsants for off-label uses, followed by neurologists (9.4%), psychiatrists (2.8%), and other (46.5%). The coverage change resulted in cost savings for the plan of $0.16 per member per month. CONCLUSIONS The off-label usage pattern varied for individual anticonvulsants in 2004 and 2005. Future considerations for controlling off-label use may include requiring prior authorization and provider education.
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Stellpflug M. [Summary of Discussion Ii]. Z Evid Fortbild Qual Gesundhwes 2010; 104:386. [PMID: 20707976 DOI: 10.1016/j.zefq.2010.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Kmietowicz Z. Company pays over $81m for allegedly promoting topiramate for unapproved uses. BMJ 2010; 340:c2848. [PMID: 20508021 DOI: 10.1136/bmj.c2848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kmietowicz Z. Doctors warn against using Avastin for macular degeneration. BMJ 2010; 340:c2483. [PMID: 20453011 DOI: 10.1136/bmj.c2483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cohen J, Wilson A, Faden L. Off-label use reimbursement. Food Drug Law J 2009; 64:391-403. [PMID: 19999289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In this study, the authors examine factors underlying payer off-label use reimbursement policies. Updating a study published 14 years ago, presenting the results of the survey of 179 payers administering public (Medicare and Medicaid) pharmacy benefits. The focus is on payers administering pharmacy benefits in the public sector for two reasons: First, transparency; there is a tendency for such payers to reveal more about their decisionmaking processes than payers that exclusively deal with the commercial market. Second, Medicare and Medicaid set the pace in terms of specific policies on off-label use reimbursement, particularly with regard to anti-cancer agents and biologics. The authors investigate the role of primary and secondary sources governing reimbursement of unlabeled indications, including biopharmaceutical compendia, peer-reviewed literature, and clinical practice guidelines. The findings point to the continued variation of off-label use reimbursement policies across payers. Furthermore, the survey data shed light on payer efforts to design off-label use reimbursement strategies, including the use of cost-effectiveness.
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Affiliation(s)
- Joshua Cohen
- Tufts Center for the Study of Drug Development, Tufts University, Boston, MA, USA
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