Trends in Insulin Prescribing for Patients With Diabetes During the COVID-19 Pandemic in the US

This cross-sectional study compares the number of insulin prescriptions filled before and during the COVID-19 pandemic.

Antidepressant prescribing patterns: a comparison of blacks and whites in a medicaid population

OBJECTIVE

This paper reports results stemming from a retrospective inquiry designed to determine the prescribing pattern of tricyclic antidepressants (TCAs) relative to selective serotonin reuptake inhibitors (SSRIs), and the subsequent effect on regimen adherence among African American (Black) and White beneficiaries enrolled in the state of South Carolina Medicaid programme.

PATIENTS AND METHODS

Adjudicated patient-level paid-claims data for the time-frame 1 January 1990 to 31 December 1994 were abstracted resulting in a statewide cohort of 8596 ambulatory beneficiaries, 18 to 64 years of age, without receipt of antidepressant pharmacotherapy in the 1-year time-frame prior to initiating a regimen of either a TCA or SSRI, and remaining Medicaid-eligible for 1 year thereafter.

RESULTS

Black race [odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.43 to 1.70], age 40 to 64 years (OR = 1.15, 95% CI = 1.06 to 1.26), and male gender (OR = 1.27, 95% CI = 1.14 to 1.41) were significant predictors of initiating antidepressant pharmacotherapy with a TCA. Relative to Whites, Blacks were found to be less likely to have obtained at least a 3-month (>/=90 days) supply of a TCA (22.1 vs 31.7%) or an SSRI (30.7 vs 36.1%), or to have obtained a 6-month (>/=180 days) supply of a TCA (6.4 vs 10.9%) or an SSRI (8.1 vs 13.2%).

CONCLUSION

Further prospective research is required to discern the reasons for observed differences in prescribing and adherence patterns for antidepressant pharmacotherapy by age, gender and race, and to foster the development of educational programming designed to ensure clinically rational and equitable access to pharmacotherapeutic innovation.

The National Oncology Working Group (NOW) initiative: payer and provider collaborations in oncology benefits management

Payers recognize the need to expand benefits management for oncology but struggle to find effective solutions amid the complexity of available therapies and skepticism from oncologists, who are facing their own set of economic pressures. An effort called the National Oncology Working Group (NOW) Initiative is trying to change the sometimes adversarial relationship between payers and oncologists through a collaborative model. The group, which is supported by pharmaceutical manufacturer sanofi-aventis, is developing patient-centered strategies for successful and sustainable oncology benefits management. The focus includes finding consensus between payers and providers and devising solutions for oncology management such as decreasing variability of cancer care and improving end-of-life care for patients with terminal illness. NOW is designing tools that will be tested in small-scale regional demonstration projects, which NOW participants anticipate will set an example for successful oncology benefits management that can be replicated and expanded.

Employer-based health initiative: impact on employees' cardiovascular outcomes

BACKGROUND

Cardiovascular disease is the primary cause of mortality among men and women in the United States. The Ready, Set, Goal program was an employer-based initiative designed to identify individuals at risk for cardiovascular disease and to offer an intervention to alter those risk factors. The program involved cardiovascular education, screening, behavior-change incentives, continuing assessment, and follow-up. Pharmacologic treatment was not part of the intervention.

OBJECTIVE

To analyze the effects of the Ready, Set, Goal pilot program in 5 employers in the United States on salient cardiovascular end points for employees who completed the program.

METHODS

The analysis used a pretest/posttest within-subjects design to compare baseline measurements with measurements for all subjects who completed a second assessment 6 months after baseline measurements. Enrollment began in June 2004 in the first site and in May 2005 in the last site; it ended in January 2006. Patient clinical data from the pilot interventions were aggregated to assess the effects of the intervention on salient cardiovascular end points for individuals who completed the Ready, Set, Goal program. Changes in short-term cardiovascular risk factors were evaluated. Descriptive measures with paired t-tests (α = 0.05) were calculated at the aggregate level for each dependent variable. Range checks were conducted on all variables for clinical validity.

RESULTS

A total of 589 subjects from 5 employer group pilot interventions completed the program. Of these, 43% were men, 60% were white, 9% were African-American, 11% were Hispanic, and 20% were categorized as "other." After the intervention, mean blood pressure, total cholesterol, and low-density lipoprotein cholesterol levels were significantly lower (P <.05) compared with baseline measurements. On average, systolic blood pressure declined by 1.9 mm Hg; diastolic blood pressure by 1.3 mm Hg; total cholesterol decreased by 5.2 mg/dL and low-density lipoprotein cholesterol by 3.4 mg/dL. Triglyceride levels increased and high-density lipoprotein levels decreased, although these changes were not significant, and neither were the mean increases in body weight. But increases in body mass index were significant.

CONCLUSIONS

A worksite cardiovascular health program can have positive effects on salient cardiovascular end points for employees. The increases in triglyceridnes and body mass index should be further explored.

Managed care and the impact of glaucoma

Changes in the healthcare system, population demographics, and treatment alternatives have contributed to an emerging awareness of glaucoma among managed care organizations. Early diagnosis and treatment are essential to thwarting the personal and economic consequences of end-stage glaucoma. Despite recognition of the need for early intervention and therapy, the literature suggests a great need still exists for improvements in lowering intraocular pressure, managing appropriate follow-up, and improving adherence to current glaucoma medication regimens. As the elderly population continues to increase, these issues will intensify and present further problems for the healthcare system. The purpose of this introductory manuscript is to highlight the literature on the clinical and economic impact of glaucoma and its importance to the managed care community. The remainder of the supplement will focus on the current management of glaucoma and the potential role of neuroprotection in this patient population.

Current landscape of insomnia in managed care

Insomnia affects a large percentage of the population, particularly the elderly. Literature reports varying estimates of prevalence, a variation that relates to the lack of definition and consistency in diagnostic criteria. Primary insomnia (not caused by known physical/mental conditions) responds to pharmacologic therapy, while secondary insomnia(resulting from other illnesses, medications, or sleep disorders) responds to pharmacologic and psychologic treatments (cognitive therapy, relaxation techniques, stimulus control). Use of certain agents in the elderly and patients with abuse/addiction potential is a concern. Medicare Part D does not cover benzodiazepines (classified as controlled substances). Nonprescription agents are affordable but have sedation and anticholinergic side effects. Medication use should be considered a possible contributing factor. Insomnia patients experience significantly more limited activity and higher total health services than those without insomnia. Annual costs are between $92.5 billion and $107.5 billion. A standard definition and better pathways to recognize and treat insomnia are needed.

Drug and medical cost effects of a drug formulary change with therapeutic interchange for statin drugs in a multistate managed Medicaid organization

OBJECTIVE

Therapeutic interchange (TI) interventions are commonly used to manage pharmacy benefit costs. While several studies have considered the effect that TI interventions have on drug costs, most have not considered the effect they have on medical management costs. The purpose of the present study was to assess drug cost and drug therapy management costs of a TI intervention following a change in the drug formulary for 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) drugs, including the conversion of atorvastatin from formulary to nonformulary status.

METHODS

A retrospective, quasi-experimental within-subjects design was used in this study. Administrative claims data were obtained from a select northeastern segment of a multistate Medicaid managed care organization (MCO). To be included in the study, patients had to meet the following criteria: (1) they must have had a minimum of 3 atorvastatin prescriptions during a 6-month enrollment phase, (2) they must have been continuously enrolled throughout the 900-day study period, and (3) they must have switched from atorvastatin to another statin between April 1, 2003, and July 31, 2003. The day of the switch from atorvastatin marked for each patient the end of the 12-month pre-TI period and the beginning of the 12-month post-TI period. Two separate dependent variables were developed: (1) statin drug costs (statin cost + dispensing fee) and (2) the costs paid by the MCO for the medical management of statin therapy, including office visit costs and the medical laboratory costs of measuring lipids and creatine kinase, and of checking liver functions. To estimate expenditures over 24 months, a panel analytic technique was used that allows each patient to serve as his or her own control. Multivariate models were used to assess the effects of the TI policy while controlling for age, gender, adjunctive dyslipidemia therapy, comorbidity, presence of a prior coronary artery event, statin compliance, cardiologist management, and disease severity.

RESULTS

Of the 3,636 patients who met the study inclusion criteria and were converted from atorvastatin to an alternate statin drug, 129 patients (3.5%) switched back to atorvastatin following the TI. The average statin cost per claim in the 12-month post-TI period was Dollars 70.93, 9.5% less than the average cost in the 12-month pre-TI period (Dollars 78.40). The average cost per patient per year (PPPY) for statin laboratory tests (lipid panels, creatine kinase tests, and liver function tests) increased by 31.5% to Dollars 16.15 in the post-TI period compared with Dollars 12.28 PPPY in the pre-TI period, and medical office visit costs increased by 44.9% to Dollars 20.70 PPPY in the post-TI period compared with Dollars 14.29 PPPY in the preperiod. These increased costs related to the medical management of statin therapy were overwhelmed by an 11.7% reduction in statin drug costs, from Dollars 793.69 PPPY in the pre-TI period to Dollars 701.01 PPPY in the post-TI period, resulting in a net 10.0% reduction for combined statin costs and related medical costs, from Dollars 820.27 PPPY in the pre-TI period to Dollars 737.87 in the post-TI period. After limiting the analysis to patients who did not convert from atorvastatin to pravastatin (which cost more than atorvastatin before the rebate) and controlling for the influence of potential confounders, statin expenditure decreased by 33% (P < 0.001). Multivariate models indicated no statistically significant differences in the costs related to the medical management of statin therapy after the TI compared with before the TI.

Managing oncology costs

This monograph will review the burden of illness in oncology, suggest a framework for evaluating oncology costs and consequences, identify economic modeling formats in cancer care, and explore methods of cost control for cancer care.

Leadership versus management: translating pharmacists' abilities into quality performance

OBJECTIVE

To describe the quality gap in health care as it was referred to in the Institute of Medicine's reports, to try to harness pharmacy's potential to improve the quality of drug therapy, and to provide insight into the elusive leadership, management, and dynamics of change.

SUMMARY

Current health care is nowhere near ideal. Successful quality initiatives have included establishing a "culture of quality" (promoting a learning organization), having good leadership, and developing strong management. Ideally, all of these concepts must be applied concurrently for the best results because using only one will not spirit medicine across the gap. To close the gap, pharmacists need to understand various types of change and select a change mechanism that will continuously improve care.

CONCLUSION

Optimizing drug therapy is both a great challenge and a great opportunity for pharmacy. AMCP's Framework for Quality Drug Therapy is a continuous quality improvement model that gives us the tools to plan, implement, and evaluate strategies to improve the quality of patient care and cross the "quality chasm."

A comparison of the cost-effectiveness of almotriptan and sumatriptan in the treatment of acute migraine using a composite efficacy/tolerability end point

OBJECTIVE

To use a composite efficacy/tolerability end point to compare the cost-effectiveness, from the perspective of a U.S. health care payer, of almotriptan and sumatriptan in the treatment of an acute migraine attack.

METHODS

The composite end point. Sustained pain free and No Adverse Events. (SNAE) was created from the sustained pain free and adverse event rates obtained in a meta-analysis of 53 placebo-controlled trials of oral triptans. The total direct cost of treating a single migraine attack was calculated from published sources.

RESULTS

In the base-case analysis, the average cost-effectiveness ratios (CERs) were 82 US dollars , 133 US dollars , and 138 US dollars (per attack at which SNAE is achieved, 2004 prices) for almotriptan 12.5 mg, sumatriptan 50 mg, and sumatriptan 100 mg, respectively; the incremental CERs for almotriptan 12.5 mg were 12 US dollars and 16 US dollars (compared with sumatriptan 50 mg and sumatriptan 100 mg, respectively) per incremental attack at which SNAE is achieved. Sensitivity analyses were conducted to explore the impact of (1) relaxing the base-case assumptions (independence of efficacy and tolerability, uniform apportionment of health service use costs across attacks, number of tablets used to treat 1 attack); (2) varying input costs; and (3) uncertainty in the efficacy and tolerability estimates from the meta-analysis. In all of these sensitivity analyses, almotriptan 12.5 mg remained cost effective compared with sumatriptan 50 mg and 100 mg.

CONCLUSION

Almotriptan was economically superior to sumatriptan in the treatment of a migraine attack.

Effects of an increase in prescription copayment on utilization of low-sedating antihistamines and nasal steroids

BACKGROUND

Health plans are using 3-tier copayment designs and other methods to control utilization that shifts drug costs to plan members. There is a need to determine the effects of increased member cost sharing on drug utilization and drug costs.

OBJECTIVE

To assess the impact of a 10 US dollars increase in prescription copayment in a public employer health plan for 2 classes of drugs used for allergic rhinitis.

METHODS

Changes in the number of prescriptions dispensed for 2 therapeutic classes.low-sedating antihistamines (LSAs) and nasal steroids (NSs).were examined 1 year prior to and 1 year after copayment increase. Relative price effects were measured as arc price elasticity, the ratio of the percent change in prescription utilization over the percent change in price, an indicator of how responsive patients are to the copayment increase.

RESULTS

Of 8,643 continuously enrolled health plan beneficiaries, 2,150 patients (24.8%) received at least 1 NS or LSA during the 2-year period of the study, from January 1, 1998, through December 31, 1999. An average 10 US dollars increase in copayment per prescription was associated with no statistically significant change in utilization of combined LSA and NS prescriptions, 2.89 per patient in 1998 and 2.94 in 1999 (P = 0.597). Health plan costs for study drugs, unadjusted for inflation, decreased by 16.3% from 86.86 US dollars per patient in 1998 to 72.68 US dollars in 1999 (P = 0.004). Health plan costs per patient per month (PPPM) for all drugs for the 2,150 allergic rhinitis patients decreased by 13% from 41.33 US dollars PPPM in 1998 to 35.93 US dollars in 1999 (P<0.001), and health plan drug costs for all 8,643 members decreased by 13% from 14.93 US dollars per member per month (PMPM) in 1998 to 12.99 US dollars in 1999 (P<0.001). The actual average copayment increase was 7.23 US dollars (a 41% increase) for LSAs, which was associated with a 14.8% increase in utilization of LSAs and an 11.8% increase in the number of patients using LSAs; the number of LSA prescriptions per patient per year was unchanged at 2.68 in 1999 versus 2.61 in 1998 (P = 0.429). The actual average copayment increase was 10.98 US dollars (71%) for NSs, which was associated with an 11.3% decrease in utilization of NSs and a 10.2% decrease in the number of users of nasals steroids in 1999; the number of nasal steroid prescriptions per patient per year was unchanged at 2.05 in 1999 versus 2.07 in 1998 (P =.842). The combined utilization of LSA and NS prescriptions increased by 8.9% following the increase in copayments for these 2 therapeutically interchangeable drugs for allergic rhinitis. LSA prescriptions were less elastic, with an unadjusted arc elasticity of 0.39, while nasal steroid prescriptions were more responsive to the copayment change, with an unadjusted arc elasticity of.0.22.

CONCLUSIONS

An average 10 US dollars increase in patient cost sharing per prescription (46.9% copayment increase) was associated with an increase in combined utilization of 2 drug classes used for allergic rhinitis (LSAs and NSs) but no change in the number of prescriptions per patient. Health plan costs decreased significantly for allergic rhinitis drugs, all drugs used by allergic rhinitis patients, and all drugs used by continuously enrolled health plan members. NSs exhibited a greater arc price elasticity compared with low-sedating oral antihistamines.

Cost-effectiveness of almotriptan and rizatriptan in the treatment of acute migraine

BACKGROUND

Migraine is a common disorder that costs US employers billions of dollars each year in missed workdays and reduced productivity. Seven triptans, including almotriptan and rizatriptan, are recommended as first-line therapy for acute migraine.

OBJECTIVE

The aim of this study was to assess the relative cost-effectiveness of almotriptan and rizatriptan in the treatment of acute migraine.

METHODS

A model was built to compare almotriptan 12.5 mg and rizatriptan 10 mg for the treatment of a single, acute migraine attack. Cost-effectiveness (in year-1999 US dollars) was evaluated from the perspective of a US health care payer. Mean and incremental cost-effectiveness ratios (CERs) were calculated. The effectiveness measure was the proportion of patients who achieved sustained freedom from pain with no adverse events (SNAE). Data on sustained pain-free outcomes and adverse-event rates were obtained from a meta-analysis of oral triptan trials. Efficacy and tolerability were assumed to be independent in the base-case scenario, so the total direct cost of treating a single migraine attack was calculated, adding drug costs to health service costs per attack.

RESULTS

In the base-case analysis, the mean CERs for almotriptan 12.5 mg and rizatriptan 10 mg were 91.12 dollars and 131.26 dollars, respectively, per attack at which SNAE was achieved after treatment. The incremental CER for almotriptan (compared with rizatriptan 10 mg) was 6.94 dollars per additional SNAE achieved. The economic benefit of almotriptan 12.5 mg was robust in a range of sensitivity analyses.

CONCLUSION

Almotriptan 12.5 mg was more cost-effective than rizatriptan 10 mg for the treatment of acute migraine in this analysis based on published data.

A comparison of office-based physician visits for irritable bowel syndrome and for migraine and asthma

Three years of data from the National Ambulatory Medical Care Survey were analyzed to assess resource utilization for patients with irritable bowel syndrome (IBS), asthma, and migraine. Adjusted for prevalence, IBS-related physician visits occurred at approximately the same rate as those for asthma and 2.6 times the rate of visits for migraine. Specialist consultations for IBS were of similar frequency to those for migraine and more frequent than those for asthma. Diagnostic and screening tests were ordered more often during IBS-related visits than during migraine- or asthma-related visits. Prescription rates were similar for all three conditions. In terms of resource consumption, this chronic disorder places a burden on patients that is comparable with that of such costly conditions as asthma and migraine.

Economic comparison of oral triptans for management of acute migraine: implications for managed care

Sound, informed decision making regarding which drugs to include on a formulary should be based on the best available evidence of their clinical efficacy and incidence of adverse events. Comparative drug costs and clinical effectiveness should also be considered during the formulary development process. Clinical trials traditionally evaluate efficacy and adverse events independently, whereas effectiveness in real-life conditions is defined as some combination of efficacy and side effects. When evaluating similar medications, head-to-head efficacy and effectiveness studies are preferred. For oral triptans (serotonin 5-HT(1B,1D) receptor agonists), there are many placebo-controlled trials and several active trials that compare newer oral triptans with sumatriptan; however, there have been few comparisons of triptans in head-to-head trials. Meta-analysis is an appropriate method to evaluate multiple clinical trials critically and combine the results. A recently published meta-analysis used patient-level data to assess efficacy and adverse events across multiple triptan clinical trials. In this analysis, we combined those results with medication costs to assess the overall value among oral triptans. Using this combined approach, almotriptan was found to have the greatest economic value. It delivers comparable efficacy, placebo-like tolerability, and the highest value when compared with other triptans currently marketed in the United States.

The impact of angiotensin-converting enzyme inhibitors on managed care: economic, clinical, and humanistic outcomes

This article examines evidence of the improved clinical, economic, and humanistic outcomes associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) in clinical practice, in particular in the areas of hypertension, diabetic nephropathies, post-myocardial infarction, and congestive heart failure. Pharmacodynamic and pharmacokinetic differences may exist among this class, however, these may not be clinically relevant when the drugs are given in equivalent doses. Although additional studies are necessary before a class effect can be assumed for each of these outcomes, it is important for clinicians to consider all of these outcomes when using ACEIs.

An economic model for a novel viral influenza diagnostic

The authors present a model that tests the economic value of a new diagnostic test that can identify type A and B influenza. Compared with traditional treatment without trying to objectively differentiate viral from bacterial infection, substantial cost savings may be achieved if diagnostic testing is appropriately utilized in a comprehensive influenza management program.

ASHP survey of ambulatory care responsibilities of pharmacists in integrated health systems--1997

The results of a national survey of the ambulatory care functions of pharmacists in integrated health systems, including managed care organizations, are reported. Persons responsible for ambulatory care pharmaceutical services in 392 integrated health systems nationwide were interviewed by telephone and asked about their systems' organizational characteristics, information systems, pharmacist functions, and performance measures. Respondents reported a range of health-system components, including acute care hospitals, home health services, managed care products, and ambulatory care centers. Approximately 27% of respondents reported that their health system had an electronic medical records system, and 23% reported having one for ambulatory patients. Approximately 49% of respondents indicated that their system had an interdisciplinary care team for ambulatory patients that included a pharmacist. Overall, distributive functions consumed the largest portion (45%) of pharmacists' time, followed by clinical (30%) and administrative (21%) activities. The percentages of time spent on the different functions varied by geographic region and type of health system. Tracking adverse drug reactions, monitoring medication compliance, using pharmacoeconomic data for formulary decision-making, conducting medication management programs, and patient counseling were routinely provided as part of ambulatory care pharmaceutical services by 75% or more of health systems. Financial performance and patient satisfaction were the most frequently used performance-evaluation measures. Overall, pharmacists providing ambulatory care services in integrated health systems spent about 45% of their time on distributive, 30% on clinical, and 21% on administrative functions.

ASHP national survey of pharmacy practice in acute care settings--1996

The results of the 1996 ASHP national survey of pharmaceutical services in nonfederal community hospitals are presented and compared with the findings of the 1994 ASHP survey. A questionnaire was mailed to pharmacy directors at hospitals randomly sampled from those registered by the American Hospital Association. A total of 713 usable surveys were returned, for a net response rate of 37.1%. Inpatient pharmaceutical services were provided an average of 17.4 hours per weekday and ambulatory care pharmaceutical services 13.3 hours per weekday. Pharmacy directors were more likely to have duties beyond the department than in 1994 (24% versus 12%). The percentage reporting a patient-focused-care model increased from 18% in 1994 to 33% in 1996. The percentage reporting some automation of drug distribution increased from 55% in 1994 to 65% in 1996. Provision of ambulatory care pharmaceutical services was indicated by 63% of respondents, and 35% indicated providing home infusion services. Compared with 1994, pharmacy departments provided more clinical services to inpatients. The most commonly offered clinical pharmacy services for inpatients were drug-food interaction screening, drug-use evaluations, adverse-drug-reaction programs, and medication error management programs. The percentage providing pharmaceutical care to some extent increased from 44% to 60%. The percentage reporting that pharmacists had the authority to initiate or modify medication orders increased from 35% to 56%. A well-controlled formulary system was in place at 60% of hospitals, while 39% reported restrictions on prescribing. Nearly three fourths of respondents reported a therapeutic interchange policy. Mean inventory cost per patient day was $4.67, a decrease from $5.62 in 1994. About 68% of inpatient pharmacy expenditures went for drugs and fluids, 27% for staff, and 5% for other noncapital expenditures. The 1996 ASHP survey revealed continued growth in various activities related to patient care, such as implementation of patient-focused care, enhanced clinical services, and therapy management programs. Although the provision of pharmaceutical care increased, ample room for growth remains.

Overview of pharmacoeconomics and pharmaceutical outcomes evaluations

The principles, methods, and applications of pharmacoeconomics and pharmaceutical outcomes evaluations are discussed. Pharmacoeconomics may be defined as balancing the cost with the consequences (outcomes) of pharmaceutical therapies and services. As a type of outcomes evaluation, pharmacoeconomics looks beyond just the direct or acquisition cost of a pharmaceutical by including its impact on total health resource utilization and costs. Outcomes research attempts to answer the question, What difference does the pharmaceutical make in patient outcomes under real-world conditions? The economic, clinical, and humanistic outcomes (ECHO) model for a pharmacoeconomic evaluation views the drug as some combination of its clinical, economic, and humanistic attributes. Safety and effectiveness are no longer the only salient attributes of a drug; the effect on total health resource utilization, cost, and quality of life must also be evaluated. The four types of pharmacoeconomic methods are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. As disease state management continues to emerge as a cost-management, quality assurance strategy, formularies per se will wane in importance and pharmacoeconomic and outcomes data will increase in relevance as health professionals endeavor to find the most efficient and effective combinations of medical care. Pharmacoeconomics as a component of outcomes research will help pharmacists decide which clinical circumstances, patient characteristics, and practice settings are most suitable for particular interventions.

A literature review comparing the economic, clinical, and humanistic attributes of dihydroergotamine and sumatriptan

The value of different pharmaceuticals in treating migraine is frequently based on clinical efficacy only. This article assumes a broader perspective and compares the clinical, economic, and humanistic attributes of two antimigraine medications, dihydroergotamine (DHE) and sumatriptan, based on a literature review. DHE is an established product with over 40 years of use in the treatment of migraine. Sumatriptan is a new product with a higher acquisition cost than DHE. Because sumatriptan costs more than DHE, the question must be asked. "Does sumatriptan provide advantages that offset this price differential?" This question reflects the growing concern among payers and patients over the cost and effectiveness of therapies. However, it is not easily answered. Direct comparative data are not available, and data sources are different for the two products. Moreover, the products are currently marketed in different dosage forms--intramuscular for DHE and subcutaneous for sumatriptan. The literature reviewed indicates that the clinical attributes of the two products are similar, with each having slightly different advantages and disadvantages. However, the DHE literature is generally limited to uncontrolled studies, whereas the sumatriptan literature reports the results of rigorously designed, randomized, double-blind, placebo-controlled clinical trials. Published data on the products' economic and humanistic attributes are limited. We concluded that the literature does provide important, albeit limited, data on the economic, clinical, and humanistic attributes of DHE and sumatriptan that permit restricted comparisons. The limitations of the data highlight the need for comparative studies of these products' multidimensional attributes both in controlled clinical trials and under actual practice conditions.

Multivariate analysis of health status scores: chronic airway disorders and the MOS SF-36

Multivariate analysis of variance (MANOVA) with follow-up canonical discriminant analysis may be used to interpret differences in health-related quality of life measured by the Medical Outcome Study Short Form 36 (MOS SF-36). Due to the moderate correlations between the 8 health dimensions of the SF-36, MANOVA is theoretically a more appropriate method than traditional univariate approaches for detecting group differences on the SF-36. Additionally, canonical discriminant analysis presents a novel approach to understanding the relationship between health dimensions of the SF-36 and model-independent variables. Results from the MANOVA and canonical discriminant analysis provide evidence of the sensitivity of the SF-36 in cross-sectional, self-reported data. Significant differences in health status (alpha less than or equal to 0.05) were found for the variables of age, and primary physician visits, and between levels of disease severity, type of breathing problem, whether patients had seen a specialist or not, use of emergency room, the comorbid states of depression and arthritis, and income. No significant differences in health status were reported between males and females or racial groups.

Influence of asthma or allergies on the utilization of health care resources and quality of life of college students

The objectives of this study were to describe the treatment regimens of college students with asthma or allergies, to determine how asthma or allergies affect the lives of college students, and to evaluate the health care resources utilized by college students with asthma or allergies. A mail survey was sent to 275 students who received treatment for asthma or allergies at the Thomson Student Health Center at The University of South Carolina (TSHC-USC) during the fall 1991 semester. This survey, consisting of 46 questions, covered three key areas: current asthma or allergy management, class and work days missed, and utilization of health care resources. Students with "asthma and allergy" missed on average 2.4 days of class during the fall semester, whereas those with "asthma only" and "allergy only" missed on average 0.8 day and 1.5 days of class, respectively. Students with "allergy only" appeared to have a greater interference in their daily class and academic activities than students with "asthma and allergy" and "asthma only." In conclusion, students reported interference in their college activities and reported missing days of work and school because of asthma or allergies. This study also showed that a majority of these college students have not received asthma or allergy patient education nor utilized appropriate asthma or allergy management skills.

Economic outcomes and contemporary pharmacy practice

Health care reform will no doubt entail substantial reorganization of provider and payer systems to facilitate competition among groups or alliances of providers and payers. Pharmacists must be positioned to assume an active and significant role in the delivery of high-quality, affordable, and accessible care. To fill this role, pharmacists need to understand and use pharmacoeconomic evaluation--economic outcomes assessment for pharmaceutical products and services. To explore the value to society of pharmaceutical products and pharmacists, direct, indirect, and intangible costs must be studied. Pharmacoeconomic evaluation includes cost-benefit, cost-effectiveness, cost-minimization, and cost-utility analyses. As analytical tools, pharmacoeconomic studies can provide valuable information concerning the costs and consequences of pharmaceutical products and services. Pharmacists can play an important role in contributing to the economic efficiency of the health care system and in ensuring that economic, clinical, and humanistic dimensions are balanced in treatment decisions.

Economic, clinical, and humanistic outcomes: a planning model for pharmacoeconomic research

Medical, ethical, and societal concerns about costs, access, and quality of care are causing health care practitioners to consider a more comprehensive model for medical decision making. Consequently, interest in research to assess the outcomes of health care has been increasing. The purpose of this paper is to explicate a theoretical framework for identifying, collecting, and using outcomes data to assess the value of pharmaceutical treatment alternatives. Causal relationships between disease, health outcomes, and decisions about medical care interventions (eg, treatment with pharmaceutical products and services) are proposed to address limitations inherent in the traditional medical decision-making model. The Economic, Clinical, and Humanistic Outcomes (ECHO) model depicts the value of a pharmaceutical product or service as a combination of traditional clinical-based outcomes with more contemporary measures of economic efficiency and quality. This integrated approach provides a theoretical basis for considering potential trade-offs among economic, clinical, and humanistic variables in optimizing the allocation of health care resources. The ECHO model is a preliminary step to modeling outcomes from pharmaceutical treatments and services. Data collection instruments need to be developed, and the proposed relationships among outcomes variables should be established empirically. The ECHO model should assist health services researchers in planning, conducting, and evaluating pharmaceutical products and services from a multidimensional perspective.

Economic impact of cost-containment strategies in third party programmes in the US (part I)

The rising cost of healthcare has strained the resources of governments, private third parties and individuals with responsibility to pay for it. Various strategies have been used in an attempt to control costs. This article examines the economic impact of 4 such strategies: (a) cost sharing; (b) prescription limits; (c) rebates; and (d) cost limits. Cost sharing has been successful at reducing utilisation of prescription drugs, although the effects have not been uniform across therapeutic categories. However, the long term effect on cost and utilisation of other medical services, and the impact on overall health status, remain largely unknown. Some evidence suggests that utilisation of other services may increase. The available data regarding drug rebate programmes have been descriptive in nature. However, the designs employed in this research do not establish a direct causal relationship between rebate programmes and changes in Medicaid drug expenditure. Furthermore, still unknown is the degree of cost shifting and the effect of the rebate programme on other large public and private drug purchasers. The Maximum Allowable Cost programme led to direct savings in drug costs, but the size of these savings was variable and uncertain because of administrative costs of the programme. The Estimated Acquisition Cost programme has not resulted in significant savings.

The financial impact of OBRA-90 on community pharmacies: an overview

The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) may be the most significant piece of legislation affecting the practice of pharmacy since the Durham-Humphrey amendments to the Food, Drug and Cosmetic Act. As part of the OBRA-90 legislation, the Health Care Financing Administration (HCFA) was required to publish estimates of the impact of the act on states, Medicaid recipients, and pharmacies. Numerous stakeholders and researchers have commented on the HCFA estimates. We have summarized the estimates available in comments and studies and conducted a sensitivity analysis on these estimates. Our results demonstrate considerable variation in the factors important in estimating the impact of OBRA-90 on pharmacy operations. This variation indicates the scarcity of empirical data needed to produce reliable impact estimates. Demonstration projects are needed to scientifically evaluate the total impact of OBRA-90 on pharmacy practice. Moreover, further investigation of the impact of the legislation on program recipients and states is warranted.

Expanding Medicaid drug formulary coverage. Effects on utilization of related services

Effects on utilization and expenditures occurring concurrently with an expansion of coverage in the South Carolina Medicaid drug formulary were investigated. Data were collected for prescriptions, physician office visits, and outpatient and inpatient hospital visits. Data were evaluated for a cohort of 12,139 individuals who had at least one prescription claim and were continuously eligible for benefits during the two-year study. A repeated measures design was employed to control the differences between subjects. A multivariate analysis of variance was used to detect overall differences in utilization and expenditures. A priori comparisons of means were performed to detect changes in levels and rates of expenditures and utilization for each service. Increases were observed in the number of prescriptions, physician visits, and outpatient visits per person while the number of inpatient hospital admissions declined. Similarly, expenditures increased for all service areas except the inpatient hospital service. The proportion of variance explained by the formulary change was small in all service areas, but would be of practical significance because of the large number of Medicaid recipients affected. From a theoretical perspective, an association of a reduction in inpatient hospital use and expenditures following the elimination of drug formulary restrictions is particularly noteworthy. These findings support the thesis that medical care services should not be viewed in isolation but rather as a system of interrelated activities. Interventions in one portion of the system are mirrored by changes in utilization of other components. Frequently, private and public medical care programs are managed with organizationally distinct benefit budgets, which are controlled independently. In view of the results of this study, this organizational approach may lead to a suboptimal allocation of resources.

Ambulatory care centers: structure, services, and marketing techniques

A generic definition for an ambulatory care center (ACC) is not apparent. ACCs differ in ownership, primary function, and services offered. ACCs are attempting to expand their patient base by providing nonemergency care, contracting with provider organizations (e.g., HMOs and PPOs), and using aggressive marketing techniques.

The effect of a Medicaid drug copayment program on the utilization and cost of prescription services

The effect of a copayment for pharmaceutical services in a Medicaid program is presented. Data were collected from Medicaid claim files in South Carolina (experimental program) and Tennessee (control program) for a 4-year period, 1976-1979. Utilization rates and expenditures for 1 year prior to copayment and 3 years after copayment were computed from a stratified sample of 18 counties. Both the level of prescriptions per eligible recipient and the slope of the utilization function after copayment were found to have declined with the implementation of copayment in South Carolina. The level of the expenditure series after copayment also declined, but the series retained a positive trend. Subsequent analysis of prescription quantity concluded that the increasing expenditure function was attributed to the inflation in cost of ingredients rather than an increase in average prescription size. The study concluded that a small (50) copayment for prescription service is a successful mechanism to control the cost and assist in financing a Medicaid prescription drug program.