Application of pharmacoeconomics to formulary decision making in managed care organizations.
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OBJECTIVE: To discuss the apparent value of incorporating pharmacoeconomic studies into pharmacy and therapeutic committee decision making; current internal and external barriers to the use of pharmacoeconomic studies; and possible solutions to the problems. STUDY DESIGN: Literature review. RESULTS: The formulary system assists healthcare providers in the evaluation, appraisal, and selection of drugs. Unfortunately, managed care organizations usually evaluate drugs exclusively on clinical efficacy, safety, and daily acquisition cost without considering overall cost effectiveness. Factors that have been impeding the use of pharmacoeconomic data include departmental budgetary constraints, tardy publications, limited reliability of available studies, and a lack of knowledge required to evaluate such studies. CONCLUSIONS: To remain competitive, managed care organizations need to incorporate pharmacoeconomic consideration into their formulary decision-making process. Performing an institutionwide economic evaluation; conducting pharmacoeconomic studies earlier, perhaps along with clinical trials; using decision analysis; developing standardized guidelines; and increasing education can help overcome current barriers. (+info)
Impact of reference-based pricing for angiotensin-converting enzyme inhibitors on drug utilization.
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BACKGROUND: Increasing copayments for higher-priced prescription medications has been suggested as a means to help finance drug coverage for elderly patients, but evaluations of the impact of such policies are rare. The objective of this study was to analyze the effect of reference-based pricing of angiotensin-converting enzyme (ACE) inhibitors on drug utilization, cost savings and potential substitution with other medication classes. METHODS: We analyzed 36 months of claims data from British Columbia for 2 years before and 1 year after implementation of reference-based pricing (in January 1997). The 119,074 patients were community-living Pharmacare beneficiaries 65 years of age or older who used ACE inhibitors during the study period. The main outcomes were changes over time in use of ACE inhibitors, use of antihypertensive drugs and expenditures for antihypertensive drugs, as well as predictors of medication switching related to reference-based pricing. RESULTS: We observed a sharp decline (29%) in the use of higher-priced cost-shared ACE inhibitors immediately after implementation of the policy (p < 0.001). After a transition period, the post-implementation utilization rate for all ACE inhibitors was 11% lower than projected from pre-implementation data. However, overall utilization of antihypertensives was unchanged (p = 0.40). The policy saved $6.7 million in pharmaceutical expenditures during its first 12 months. Patients with heart failure or diabetes mellitus who were taking a cost-shared ACE inhibitor were more likely to remain on the same medication after implementation of reference-based pricing (OR 1.12 [95% confidence interval, CI, 1.06-1.19] and 1.28 [95% CI 1.20-1.36] respectively). Patients with low-income status were more likely than those with high-income status to stop all antihypertensive therapy (OR 1.65 [95% CI 1.43-1.89]), which reflects a general trend toward discontinuation of therapy among these patients even before implementation of reference-based pricing. INTERPRETATION: Reference-based pricing in British Columbia achieved a sustained reduction in drug expenditures, and no changes in overall use of antihypertensive therapy were observed. Further research is needed on the overall health and economic effects of such policies. (+info)
Recent progress in alpha 1-adrenoceptor pharmacology.
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The adrenoceptors (ARs) play a key role in the modulation of sympathetic nervous system activity and are a site of action for many clinically important therapeutic agents. The alpha1-adrenoceptor subtypes (alpha1A-, alpha1B-, and alpha1D-AR) play a prominent role in regulating vascular tone and hypertrophic growth of smooth muscle and cardiac cells. Their functional characteristics with respect to ligand binding and second messenger utilization have been well described. Here, we review recent progress on subtype-specific subcellular localization, participation in signaling cascades, and the pivotal function of alpha1-ARs, as delineated through studies on genetically engineered animals. Together, these findings will provide new insights into the physiological and pathophysiological roles of the alpha1-ARs. (+info)
Current indications for ACE inhibitors and HOPE for the future.
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Angiotensin-converting enzyme (ACE) inhibitors are effective in several disease states such as congestive heart failure, myocardial infarction, and diabetes. This article reviews the evidence supporting the clinical use, efficacy, and cost effectiveness of ACE inhibitors in these various disease states. With the findings of the Heart Outcomes Prevention Evaluation trial, these agents may now have a positive impact on the primary prevention of coronary artery disease. New and ongoing trials will provide more information about the role of ACE inhibitors in coronary artery disease. (+info)
The hidden costs of arthritis treatment and the cost of new therapy--the burden of non-steroidal anti-inflammatory drug gastropathy.
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Pain is very common throughout the world and is an increasing problem in the ageing population. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed to treat pain and many are also available without prescription, or over the counter. These drugs are effective painkillers, but they can also have severe adverse effects, particularly on the upper gastrointestinal (GI) tract. Therapeutic decisions should be made using the best available evidence and there is a growing body of evidence showing that the new specific cyclooxygenase-2 (COX-2) inhibitors, or coxibs, are effective pain killers that do not cause GI harm. The risks associated with the use of NSAIDs are substantial, with a 1 in 1200 chance of dying from a major GI adverse effect after 2 months of NSAID therapy. These risks increase with age and are avoidable. The costs associated with the prevention and treatment of NSAID-induced GI adverse effects can more than double the cost of the original therapy and should be included when costing NSAID interventions. Taking these costs into account, the expense of switching from a conventional NSAID to a coxib is relatively modest. Compared with other interventions that society may be willing to consider to prevent one death, such as those for the rail (15 million Pounds) and road (100,000 Pounds) networks in the UK, the cost of preventing one death by switching to a coxib is much lower, with a high estimate being 20,000-30,000 Pounds, which is in line with the accepted benchmarks for the cost-effectiveness of medical interventions. (+info)
Pharmaceutical industry research and cost savings in community-acquired pneumonia.
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OBJECTIVE: To provide financial justification for continuing pharmaceutical research in an environment that has met with increasing resistance from insurance carriers to paying for the care of patients enrolled in research studies. STUDY DESIGN: Matched case-control study of patients enrolled into inpatient community-acquired pneumonia (CAP) pharmaceutical research protocols. PATIENTS AND METHODS: Case patients were enrolled into a CAP pharmaceutical research trial. Control patients were obtained from a prospective cohort study of CAP. Cases were matched to controls on the basis of age, sex, pneumonia severity index (PSI) grade, and comorbid illnesses as measured by the PSI and Acute Physiologic and Chronic Health Evaluation II (APACHE II) scoring systems. Financial data were obtained from hospital billing records. RESULTS: Twenty-five cases were identified and matched to appropriate controls. There was no statistically significant difference in mean PSI and APACHE II scores between cases and controls. There was a significant reduction in the total charges for hospital care of patients enrolled into a pharmaceutical industry trial ($6267 vs $9979; P = .03). As expected, the most dramatic reduction was in pharmacy charges ($642 vs $1797; P = .002), but there were trends toward lower charges in all cost subgroups. Interestingly, there was also a strong trend toward reduced length of hospital stay associated with enrollment in a pharmaceutical trial (4.5 vs 6.0 days; P = .06). CONCLUSION: Enrollment in a pharmaceutical research protocol results in significant cost savings in patients admitted to the hospital with CAP and may lead to earlier hospital discharge. (+info)
Treatment for anthracycline-pretreated metastatic breast cancer.
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As a result of increasing anthracycline use earlier in the course of breast cancer, oncologists are frequently faced with the challenge of treating patients whose disease has progressed during or following anthracycline therapy or who are ineligible for further anthracycline therapy. Many of these women remain candidates for cytotoxic chemotherapy, and several treatment options exist. Until recently, the taxanes, docetaxel in particular, were widely regarded as the most effective therapy for these patients, based on a survival advantage observed with docetaxel. However, a recent phase III study demonstrated that the addition of capecitabine to docetaxel results in superior overall survival (with a 3-month improvement in median survival), superior time to disease progression, and a superior response rate, with a manageable safety profile. Capecitabine/docetaxel is the first cytotoxic combination to improve survival over standard monotherapy in patients with anthracycline-pretreated metastatic breast cancer. Moreover, the survival benefit can be attributed to the addition of capecitabine, as it was achieved despite the lower dose of docetaxel administered in the combination arm. Quality of life was maintained with capecitabine/docetaxel combination therapy, which further supports the use of this regimen in patients with anthracycline-pretreated metastatic breast cancer. Pharmacoeconomic modeling using the data from the phase III trial has shown that the capecitabine/docetaxel combination therapy is highly cost effective when compared with other cancer treatments that improve survival. This review describes several treatment options for patients with anthracycline-pretreated breast cancer, including the phase III data (efficacy, tolerability, quality of life, and pharmacoeconomics) for capecitabine plus docetaxel in this setting. (+info)
Cost-effective use of NSAIDs: issues pertinent to coxib use in managed care.
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The gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs (NSAIDs) is well established. The management of patients requiring NSAID therapy has been revolutionized by the cyclooxygenase (COX)-2 inhibitors (coxibs), equally efficacious agents that significantly reduce GI complications. The safety advantage of coxibs comes at the expense of higher drug acquisition costs. To make informed decisions regarding the "value" of these added expenditures, a careful analysis of the clinical and economic impact of these new agents is warranted. This article focuses on the issues pertinent to healthcare payers as they evaluate the coxibs, and provides a review of the studies that calculate the cost-effectiveness of these innovative drugs in a number of patient populations and health systems. (+info)