Price variation in the most commonly prescribed ear drops in Southern California

Cost-Effectiveness of Topical Prophylaxis Against Tympanostomy Tube Otorrhea: An Economic Decision Analysis

Objective

To evaluate the cost-effectiveness of various topical prophylaxis strategies against posttympanostomy otorrhea using a break-even analysis.

Study Design

An economic decision analysis of data collected from purchasing records and the literature.

Setting

An academic center.

Methods

Costs of various strategies were calculated by querying our institution's pharmacy as well as GoodRX.com drug prices. Posttympanostomy otorrhea rates were acquired from a review of the literature. Costs for treatment of otorrhea were based upon our institution's self-pay patient charges. A break-even analysis was performed to determine the required absolute risk reduction (ARR ) in otorrhea rate to make prophylactic treatment cost-effective.

Results

The most expensive strategy ciprofloxacin/hydrocortisone otic ($626.83) was not cost-effective unless the rate of postoperative otorrhea was greater than 92% or if the cost of otorrhea treatment exceeded $4477.36. The cheapest antibiotic/steroid combination, ciprofloxacin/dexamethasone otic ($72.25) was cost-effective (ARR 10%). Using a conservative initial otorrhea rate (14%) and weighted cost of treatment ($683.39), the most expensive cost-effective prophylactic intervention possible was $95.67.

Conclusion

Prophylaxis against posttympanostomy otorrhea can be cost-effective. Physicians should consider the cost of prophylaxis at their institution as well as the patient's postoperative risk of otorrhea when making treatment decisions.

Spatial accessibility and travel to pharmacy by type in the Detroit region

BACKGROUND

Community pharmacies are a critical part of the health care provision system. Yet less is understood about the spatial accessibility to pharmacies and how people travel to reach these services.

OBJECTIVES

This study compared spatial accessibility and actual travel to different types of pharmacies among selected neighborhoods in the Detroit region.

METHODS

Three types of neighborhoods were selected and compared, including two lower income Black urban neighborhoods of high-density and four upper income White suburbs (two of low density and two of high density). Spatial accessibility was computed by pharmacy type and compared among neighborhoods using ANOVA. Pharmacy trips reported in a travel survey were geocoded and linked with community pharmacies in a list generated from ReferenceUSA business data. Destination choices were mapped and the relationship between spatial accessibility and actual distance traveled was examined using ordinary least squares regressions.

RESULTS

On average, urban residents in Detroit had higher access to local independent pharmacies (0.74 miles to the nearest one) but relatively lower access to national chains (1.35 miles to the nearest one), which most residents relied on. Urban residents also tended to shop around more for services even among national chains. In fact, they bypassed nearby local independent pharmacies and traveled long distances to use farther pharmacies, primarily national chains. The average trip distance to pharmacy was 2.1 miles for urban residents, but only 1.1 miles and 1.5 miles for residents in high-density suburbs and low-density suburbs, respectively.

CONCLUSION

Supposedly good spatial access considering all pharmacies together may mask excessive burden in reaching the pharmacy services needed in low-income minority urban communities, as shown in the case of Detroit. Thus, when mapping pharmacy deserts, it is important to distinguish spatial accessibility among different pharmacy types.

The rising cost of rhinologic medications

BACKGROUND

The high prescription drug cost in the United States may negatively affect patient prognosis and treatment compliance.

OBJECTIVE

To fill the knowledge gap and inform clinicians regarding rhinology medications price changes by evaluating trends in price changes of highly used nasal sprays and allergy medications.

METHODS

The 2014-2020 Medicaid National Average Drug Acquisition Cost database was queried for drug pricing information for the following classes of medications: intranasal corticosteroids, oral antihistamines, antileukotrienes, intranasal antihistamines, and intranasal anticholinergics. Individual medications were identified by Food and Drug Administration-assigned National Drug Codes. Per unit, drug prices were analyzed for average annual prices, average annual percentage price changes, and inflation-adjusted annual and composite percentage price changes.

RESULTS

Beclometasone (Beconase AQ, 56.7%, QNASL, 77.5%), flunisolide (Nasalide, -14.6%), budesonide (Rhinocort Aqua, -1.2%), fluticasone (Flonase, -6.8%, Xhance, 11.7%), mometasone (Nasonex, 38.2%), ciclesonide (Omnaris, 73.8%), combination azelastine and fluticasone (Dymista, 27.3%), loratadine (Claritin, -20.5%), montelukast (Singulair, 14.5%), azelastine (Astepro, 21.9%), olopatadine (Patanase, 27.3%), and ipratropium bromide (Atrovent, 56.6%) had an overall change in inflation-adjusted per unit cost between 2014 and 2020 (% change). Of 14 drugs evaluated, 10 had an increase in inflation-adjusted prices, for an average increase of 42.06% ± 22.27%; 4 of 14 drugs had a decrease in inflation-adjusted prices, for an average decrease of 10.78% ± 7.36%.

CONCLUSION

The rising cost of highly used medications contributes to increased patient acquisition costs and may pose barriers of drug adherence to particularly vulnerable populations.

Price Differences Between Otic and Ophthalmic Drops

OBJECTIVE

Otic drops are one of the most frequently prescribed medications in otolaryngology. However, some forms of these drops can be very expensive, and ophthalmic formulations are sometimes used by practitioners to decrease the cost for their patients. The goal of this study is to determine the cost differential between otic and ophthalmic drops.

METHODS

Pharmacies in New York City, Chicago, and Portland were surveyed in the span of 6 weeks by telephone to evaluate the current prices of various otic and ophthalmic drops commonly prescribed by otolaryngologists.

RESULTS

A total of 83 pharmacies were surveyed. Surveyed drugs included ciprofloxacin/dexamethasone (cip/dex) otic, neomycin/polymyxin B sulfates/hydrocortisone (neo/poly/HC) otic, acetic acid (AA) otic, acetic acid/hydrocortisone (AA/HC) otic, ofloxacin otic, ofloxacin ophthalmic, and tobramycin/dexamethasone (tob/dex) ophthalmic. Per milliliter, cip/dex otic was consistently the most expensive, with a median price of $38.00 per milliliter. Among the antibiotic drops, neo/poly/HC otic was the least expensive formulation with a median price of $11.60 per milliliter. Ofloxacin ophthalmic was significantly less expensive than the otic formulation, at $11.00 and $31.00 per milliliter, respectively (adjusted p < 0.001). In general, otic and ophthalmic formulations were not significantly different according to manufacturing information, although ophthalmic drops were more often packaged in a sterile fashion and with less abrasive ingredients for use in the more sensitive tissue of the eye.

CONCLUSION

Significant and meaningful price differences exist between otic and ophthalmic drops. Given the safety of ophthalmic drops used in the ears, they may be a more cost-effective alternative to traditionally prescribed otic drops when clinically appropriate.

Variability in Price of Generic Antipsychotic Medications at Community Pharmacies

OBJECTIVE

This study aimed to examine variability in pricing of generic antipsychotic medications in a diverse metropolitan area and to determine whether prices varied by pharmacy type.

METHODS

A cross-sectional survey was conducted of pharmacy-level variability in retail cash prices for a 30-day supply of one first-generation and five generically available second-generation antipsychotic medications at community pharmacies in the Kansas City metropolitan area. All community pharmacies in the area were identified (N=281), and 94% (N=265, with 147 in Missouri and 118 in Kansas) responded to phone queries between April 25 and May 25, 2017, requesting the cash price of a 30-day supply of each of the six antipsychotics. All included pharmacies were categorized as a nationwide chain (N=182), grocery store (N=53), or independent pharmacy (N=30).

RESULTS

Retail cash prices varied for all antipsychotic medications, with significant differences in price by pharmacy type. Price variation across all pharmacy types was lowest for haloperidol ($20-$102.99) and highest for aripiprazole ($29.99-$1,345.00). Pairwise comparisons showed that chain pharmacies had higher prices, compared with independent pharmacies, for all medications except haloperidol. Overall, chain pharmacies had the highest prices, with prices at grocery store pharmacies averaging $180 lower than chain pharmacies, and independent pharmacies averaging $415 lower than chain pharmacies.

CONCLUSIONS

This report is the first on pharmacy-level variability in the costs of generic antipsychotic treatment options for schizophrenia. Appreciable differences were found in the costs of generic antipsychotics. Understanding variability in antipsychotic pricing may be important for providers serving uninsured patients.

Financial Transactions from Manufacturers to Otolaryngologists in 2018

OBJECTIVE

To characterize in depth non-research and research payments from industry to otolaryngologists in 2018 with an emphasis on product types.

METHODS

Centers for Medicare and Medicaid Services Open Payments program was used for data collection: payment amount, the nature of payments, products associated with the payments, date of the payments, and companies making the payments were studied. Products associated with the payments were classified by categorical type. Descriptive statistics were used to analyze the data.

RESULTS

There were 70,172 payments for a total of $11,001,875 made to otolaryngologists in 2018 with a median payment of $19. Food and beverage had the highest number of payments made (89.96%). Consulting fees (33.46%) composed the highest total payment amount. The two companies that contributed the highest amount were Stryker Corporation and Intersect ENT Inc. Sinus conditions had the most products within the top 25 products associated with payments. The top five products with the highest payments received were for balloon sinus dilation, nasal spray, sinus implant, Botox, and cochlear implant. There was a bimodal payment distribution demonstrating a higher number of payments made in the spring and fall.

CONCLUSION

Our study is the first to review payments to otolaryngologists in 2018 and classify these payments into product types. The products and companies that contributed the highest payments were associated with sinus conditions. The products that dominated in each subspecialty of otolaryngology coincide with clinical practice trends and emerging technologies.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E388-E394, 2021.

Ophthalmic medication price variation across the United States: Anti-inflammatory medications

Background:

Cost-related nonadherence to medication can impact ophthalmic treatment outcomes. We aimed to determine whether medication prices vary between US cities and between different types of pharmacies within one city.

Methods:

We conducted a phone survey of eight nationwide and five independent pharmacies in five cities across the United States: Boston, Massachusetts; Charlotte, North Carolina; Denver, Colorado; Detroit, Michigan; and Seattle, Washington. A researcher called each pharmacy asking for price without insurance for four common anti-inflammatory ophthalmic medications: prednisolone acetate, prednisolone sodium phosphate, difluprednate (Durezol™), and loteprednol etabonate (Lotemax™).

Results:

Prednisolone sodium phosphate price could only be obtained by a small subset of pharmacies (45.2%) and was excluded from additional analysis; however, preliminary data demonstrated lower cost of prednisolone sodium phosphate over prednisolone acetate. Three-way analysis of variance revealed no interaction between pharmacy type (chain versus independent), city, and drug (F = 0.40, p = 0.92). A significant interaction was identified between pharmacy type and drug (F = 5.0, p = 0.008), but not city and pharmacy type (F = 0.66, p = 0.62) or city and drug (F = 0.27, p = 0.97). Average drug prices were lower at independent pharmacies compared with chain pharmacies for difluprednate (US$211.36 versus US$216.85, F = 1.09, p = 0.297) and significantly lower for loteprednol etabonate (US$255.49 versus US$274.86, F = 14.7, p < 0.001). Prednisolone acetate was cheaper at chain pharmacies, but not statistically significantly cheaper (US$48.82 versus US$51.61, F = 0.34, p = 0.559).

Conclusions:

Medication prices do not differ significantly between US cities. High variation of drug prices within the same city demonstrates how comparison shopping can provide cost savings for patients and may reduce cost-related nonadherence.

Validation of a septoplasty deformity grading system for the evaluation of nasal obstruction

OBJECTIVES/HYPOTHESIS

We developed and validated a septal deformity grading (SDG) system that accounts for anatomic location and grading of deformity severity.

STUDY DESIGN

Retrospective cohort study.

METHODS

Subjects were patients with nasal obstruction presenting to University of California, Irvine Medical Center. Subjects were given pre- and postoperative Nasal Obstruction Symptom Evaluation (NOSE) questionnaires and were evaluated by a facial plastic surgeon using our septal deformity grading (SDG) system. Validity and reliability analyses were conducted on the SDG results. Statistical analyses were conducted on SDG and NOSE data to assess and compare instruments, and to validate the SDG instrument using the NOSE instrument.

RESULTS

One hundred thirty-five patients met inclusion criteria. Cronbach's α was ≥ 0.7 for SDG and pre- and postoperative NOSE scores. There was a significant difference in pre- and postoperative NOSE scores (Z score = -7.21, P < .001). Correlations between postoperative NOSE and SDG scores were significant (P = .014), and convergent construct validity was achieved. There was a significant difference in SDG scores between primary versus revision operations (P < .001), history versus no history of nasal trauma, and nasal/septal surgery (P = .025, P = .003, respectively). The odds of having a revision operation were 2.3 times higher for high SDG scores (P < .001), of having a history of nasal trauma were 1.33 times higher for high SDG scores (P = .014), and of having a history of nasal/septal surgery were 2.9 times higher for low SDG scores.

CONCLUSIONS

Our SDG system addresses the challenge of providing objective anatomic information on the severity of nasal septal deformities, and may be valuable when used in conjunction with subjective data gathered from the NOSE questionnaire.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:586-593, 2019.

Tympanostomy tube placement and ear drops: Evidence-based cost saving models

OBJECTIVES/INTRODUCTION

Tympanostomy tube placement is the most common surgical procedure in the pediatric population with important financial implications to our healthcare institutions. The purpose of this study is to apply various cost models in different clinical environments to determine the most cost effective way to prescribe ear drops after tympanostomy tube insertion.

METHODS

Two distinct practice models were designed: a Uniform Treatment Model and a Disease Specific Model. Different cost simulations were run based on which medication(s) was chosen for all tympanostomy tube cases performed over the course of 1 year in a practice composed of four pediatric otolaryngologist. Two categories of ear drop medications were seen: high cost and low cost. The cost associated with initiation of drops in the operating room versus initiation as an outpatient via a prescription was evaluated.

RESULTS

In both Uniform Treatment and Disease Specific Models, the most expensive simulations included antibiotic/steroid combination drop use intraoperatively. The treatment with an antibiotic/steroid combination drop was lower when delayed until the post-operative period. The hospital cost for ear drops increased by as much as 478% when dispensed within the operating room rather than from the hospital's outpatient pharmacy.

CONCLUSIONS

Otolaryngologists should make an effort to become familiar with the cost of ototopical medications and the significant variability between inpatient and outpatient settings. Cost of ototopical agents should be shifted to the institution's outpatient pharmacy whenever possible especially for branded, higher cost combination drops. Patients should be treated based on the status of their ear disease at time of middle tube insertion.

Steroid Versus Antibiotic Drops in the Prevention of Postoperative Myringotomy Tube Complications

Objectives:

To determine the incidence of early postoperative tympanostomy tube insertion otorrhea and obstruction in pediatric patients receiving antibiotic ear drops with or without steroid perioperatively.

Methods:

A retrospective chart review was performed on patients who underwent outpatient myringotomy and tube placement. Patients from June 2013 to February 2014 received ciprofloxacin/dexamethasone perioperatively while patients from May 2014 to April 2015 received ofloxacin. Statistical analysis was performed to compare outcomes between the cohorts.

Results:

One hundred thirty-four patients received topical ciprofloxacin/dexamethasone, and 116 patients received topical ofloxacin. The rate of postoperative otorrhea was 5.2% for the ciprofloxacin/dexamethasone group and 8.2% for the ofloxacin group. Tube obstruction was seen in 6.0% of the ciprofloxacin/dexamethasone group and 5.2% in the ofloxacin group. Neither outcome had a statistically significant difference ( P = .21 and .85, respectively). There was no difference in the rate of effusion at the time of tube placement between the 2 cohorts ( P = .16), and this included subgroup analysis based on effusion type (mucoid, purulent, serous). Patients with a mucoid effusion at the time of surgery were more likely to experience otorrhea/obstruction than patients with dry ears (odds ratio = 2.23, P = .02).

Conclusion:

No significant difference in the incidence of immediate postoperative tympanostomy tube otorrhea or obstruction was seen between the antibiotic-steroid and antibiotic alone cohorts, regardless of effusion type. Overall, patients with mucoid effusions are more likely to develop tube otorrhea or obstruction at follow-up. Cost-effective drops should be used when prescribing topical therapy to prevent complications after ear tubes.