Projecting future drug expenditures--2009

Antimicrobial stewardship program (ASP): an effective implementing technique for the therapy efficiency of meropenem and vancomycin antibiotics in Iranian pediatric patients

Background

Antimicrobial stewardship program (ASP) is a distinguished method to improve the prescription and efficacy of antibiotics.

Aim

The efficacy of ASP and conventional methods was compared to measure the effectiveness of meropenem (MPM) and vancomycin (VMN) antibiotics in pediatric patients.

Design

In an interventional quasi-experimental study, 135 children admitted in Children’s Hospital affiliated to University of Medical Sciences in time periods of 2014–2015 and 2015–2016 were assessed.

Methods

The conventional and ASP methods in 2014–2015 and 2015–2016 were respectively utilized to provide the best antimicrobial therapy of MPM and VMN antibiotics in patient children. The data of mortality rate (MR), antibiotic prescription (AP), antibiotic dose (ADe), antibiotic duration (ADn), length of hospital stay (LOHS), and blood cultures (BCs) were compared across the years using the Chi square, independent t test, and Fisher’s exact test.

Results

The levels of MR, AP, ADe, ADn, LOHS, and positive BCs using the ASP method in 2015–2016 were significantly lower those of in 2014–2015 using the conventional one (p < 0.05).

Conclusions

The ASP method versus conventional one with a better efficacy can be employed as an antibiotic administration guide for MPM and VMN in the therapy of patients in community-based hospitals.

Utilization of Pharmaceutical Patient and Prescription Assistance Programs via a Pharmacy Department Patient Assistance Program for Indigent Cancer Patients

BACKGROUND

With the advances in cancer treatments, mortality rates in the United States have been consistently falling but they are accompanied by substantial increases in the cost of cancer care. Patient and prescription assistance programs (PPAPs) are offered by pharmaceutical manufacturers to provide free medications to medically indigent patients. To assist the Cancer Care Center (CCC) at Nassau University Medical Center (NUMC) with drug costs for chemotherapies, the pharmacy department uses a patient assistance program (PAP) to obtain medications from the drug companies at no cost.

PURPOSE

This study evaluates the impact of the PAP at a public hospital from which indigent cancer patients obtain assistance for chemotherapy.

METHODS

We followed all patients requiring assistance with chemotherapy who enrolled in the PAP from January 1, 2011 through December 31, 2012. Medications included both oral and parenteral chemotherapy drugs and antiemetics used in the outpatient clinic setting.

RESULTS

The program served 347 patients in 2011 and 579 patients in 2012. The total number of visits in the clinic over 24 months was 9,405. The total cost savings of the medications was $1,066,000 in 2011 and $1,715,538 in 2012.

CONCLUSIONS

A pharmacy-based PAP to procure free medications from PPAPs for cancer patients has helped to defray the expense of providing care at NUMC, increased patients' compliance with chemo protocols, and allowed many patients to receive the treatment they otherwise would not be able to afford. The combination of PPAPs and PAP provides a safety net to ensure that indigent cancer patients receive needed prescription medications in the outpatient clinic setting.

Accuracy of annual prescription drug expenditure forecasts in AJHP

PURPOSE

The accuracy of the forecasts of drug expenditures in nonfederal hospitals and clinics published annually in the American Journal of Health-System Pharmacy (AJHP) relative to the accuracy of forecasts produced by the Centers for Medicare and Medicaid Services (CMS) was evaluated.

METHODS

AJHP-published forecasts of drug expenditure growth for nonfederal hospitals (for the years 2003 through 2013) and clinics (for the years 2004 through 2013) were compared with data on actual growth. Data on actual and projected growth published by CMS were analyzed for the years 2003 through 2012. The mean absolute error and directional accuracy of the forecasts published in AJHP for nonfederal hospitals and clinics and the CMS forecasts were determined and compared.

RESULTS

Actual spending growth was within the range of the forecast published in AJHP for 2 of 11 years for nonfederal hospitals and for 3 of 10 years for clinics; the forecasts for nonfederal hospitals and clinics were directionally accurate 27.3% and 60.0% of the time, respectively. The mean absolute errors of the AJHP-published drug expenditure forecasts for the nonfederal hospital and clinic sectors were 2.0 and 4.7 percentage points, respectively. The CMS forecasts of overall drug spending were directionally accurate 70% of the time, and the mean absolute error (2.2 percentage points) was not statistically different from that of either sector forecast published in AJHP.

CONCLUSION

The annual drug expenditure forecasts published in AJHP have been reasonably accurate for predicting growth in prescription expenditures when compared with other available drug expenditure forecasts.

Adjusting for Drug Wastage in Economic Evaluations of New Therapies for Hematologic Malignancies: A Systematic Review

Purpose:

As costs of cancer care rise, there has been a shift to focus on value. Drug wastage affects costs to patients and health care systems without adding value. Historically, cost-effectiveness analyses have used models that assume no drug wastage; however, this may not reflect real-world practices. We sought to identify the frequency of drug wastage modeling in economic evaluations of modern parenteral therapies for hematologic malignancies.

Methods:

We conducted a systematic literature review of economic evaluations of new US Food and Drug Administration–approved parenteral chemotherapies with indications for the treatment of hematologic malignancies. The primary outcome of interest was the proportion of studies that modeled drug wastage in base-case analyses. If wastage was considered in primary analyses, we reported the impact of wastage on incremental cost-effectiveness ratios (ICERs) and drug acquisition costs.

Results:

Wastage was considered in base-case analyses in less than one third of all publications reviewed (12 of 38; 32%). Of these, two studies went on to complete sensitivity analyses and reported significant changes in the calculated ICER as a result. In one study, the ICER increased by 32%, and in the second, accounting for wastage changed a positive ICER to a dominant result.

Conclusion:

Potential costs associated with drug wastage are considered in only one third of modern cost-effectiveness models. The impact of wastage on calculated ICERs and drug acquisition costs is potentially substantial. The modeling of wastage in base-case and sensitivity analyses is recommended for future economic evaluations of new intravenous therapies for hematologic malignancies.

An Anticancer Drug Unit for the whole provincial oncologic network of Piacenza: improving safety and savings

In recent years, the expenditure for cancer care is increased largely due to the increase in cancer prevalence, demographic changes and incorporation into clinical practice of new and expensive drugs. For these reasons, solutions to contain costs are necessaries. The drugs-related expenditure is proportionally higher in oncology than in other medical specialties and overcomes staffing costs for outpatient care. The introduction of additional measures to contain and reduce expenditures such as waste reduction and human resources optimization is highly desirable. On April 2013, we started a day-to-day monitoring of the consumption of drugs and developed an internal protocol for waste minimization, consisting of five measures. A computerized research through Medline, Cancerlit and Embase was performed, applying the words drug waste, cost-containment, Anticancer Drug Unit and stability instructions. Articles and abstracts were also identified by back-referencing from other relevant papers. Selected for the present review were papers published in English without limit of year. The day-to-day monitoring of the consumption of drugs and the internal protocol for waste minimization were able to achieve a saving of <euro>15,700 every month. The projection of an annual cost-saving result of <euro>188.00 corresponds to a recovery of 4 % on the spending for oncologic drugs. Our data show that in a proper structure working according to the standards of quality, safety and sterility, preserving and reusing the drug waste within the limits imposed by the datasheets, it is possible to achieve a cost-containment policy and produce durable benefits.

Taking stock of medication wastage: Unused medications in US households

BACKGROUND

Despite the potential deleterious impact on patient safety, environmental safety and health care expenditures, the extent of unused prescription medications in US households and reasons for nonuse remain unknown.

OBJECTIVE

To estimate the extent, type and cost of unused medications and the reasons for their nonuse among US households.

METHODS

A cross-sectional, observational two-phased study was conducted using a convenience sample in Southern California. A web-based survey (Phase I, n = 238) at one health sciences institution and paper-based survey (Phase II, n = 68) at planned drug take-back events at three community pharmacies were conducted. The extent, type, and cost of unused medications and the reasons for their nonuse were collected.

RESULTS

Approximately 2 of 3 prescription medications were reported unused; disease/condition improved (42.4%), forgetfulness (5.8%) and side effects (6.5%) were reasons cited for their nonuse. "Throwing medications in the trash" was found being the common method of disposal (63%). In phase I, pain medications (23.3%) and antibiotics (18%) were most commonly reported as unused, whereas in Phase II, 17% of medications for chronic conditions (hypertension, diabetes, cholesterol, heart disease) and 8.3% for mental health problems were commonly reported as unused. Phase II participants indicated pharmacy as a preferred location for drug disposal. The total estimated cost for unused medications was approximately $59,264.20 (average retail Rx price) to $152,014.89 (AWP) from both phases, borne largely by private health insurance. When extrapolated to a national level, it was approximately $2.4B for elderly taking five prescription medications to $5.4B for the 52% of US adults who take one prescription medication daily.

CONCLUSION

Two out of three dispensed medications were unused, with national projected costs ranging from $2.4B to $5.4B. This wastage raises concerns about adherence, cost and safety; additionally, it points to the need for public awareness and policy to reduce wastage. Pharmacists can play an important role by educating patients both on appropriate medication use and disposal.

Drug waste minimization as an effective strategy of cost-containment in oncology

Background

Sustainability of cancer care is a crucial issue for health care systems worldwide, even more during a time of economic recession. Low-cost measures are highly desirable to contain and reduce expenditures without impairing the quality of care. In this paper we aim to demonstrate the efficacy of drug waste minimization in reducing drug-related costs and its importance as a structural measure in health care management.

Methods

We first recorded intravenous cancer drugs prescription and amount of drug waste at the Oncology Department of Udine, Italy. Than we developed and applied a protocol for drug waste minimization based on per-pathology/per-drug scheduling of chemotherapies and pre-planned rounding of dosages.

Results

Before the protocol, drug wastage accounted for 8,3% of the Department annual drug expenditure. Over 70% of these costs were attributable to six drugs (cetuximab, docetaxel, gemcitabine, oxaliplatin, pemetrexed and trastuzumab) that we named ‘hot drugs’. Since the protocol introduction, we observed a 45% reduction in the drug waste expenditure. This benefit was confirmed in the following years and drug waste minimazion was able to limit the impact of new pricely drugs on the Department expenditures.

Conclusions

Facing current budgetary constraints, the application of a drug waste minimization model is effective in drug cost containment and may produce durable benefits.

Documenting the Benefits and Cost Savings of a Large Multistate Cancer Pathway Program From a Payer's Perspective

Broadly implemented clinical pathways can achieve reasonable physician compliance, resulting in substantial cost savings.

Stability of infliximab in polyvinyl chloride bags

PURPOSE

The stability of prepared infusions of the tumor necrosis factor (TNF)-α agent infliximab after storage for up to two weeks was investigated.

METHODS

To determine the feasibility of liberalized expiration dating of infliximab (current recommendations call for the infusion of prepared doses within three hours), the stability of diluted infliximab stored in polyvinyl chloride (PVC) bags at 4 °C for up to 14 days was evaluated. A known quantity of TNF-α was combined with infliximab test samples in PVC bags for one hour; immediately after the reaction period and after 7 and 14 days of storage, the residual amount of TNF-α (an indirect measure of the drug's biological activity) was analyzed via a validated enzyme-linked immunosorbent assay (ELISA).

RESULTS

The mean ± S.D. amount of TNF-α consumed by infliximab was calculated to be 24.5 ± 5.6 pg/mL at baseline, 29.0 ± 4.4 pg/mL at 7 days, and 24.8 ± 17.3 pg/mL at 14 days. At all evaluated time points, ELISA results indicated that 19-24% of the original TNF-α had been consumed by infliximab (mean ± S.D. consumption: 19.6% ± 4.5% at baseline, 23.2% ± 3.5% at 7 days, and 19.8% ± 13.8% at 14 days).

CONCLUSION

Infliximab, when prepared at a concentration of 400 μg/mL in 0.9% sodium chloride injection, incurred no loss of biological activity when stored for up to 14 days at 4 °C in PVC bags. Changing infliximab preparation practices may improve clinic efficiency by reducing patient dissatisfaction with long wait times for infusions and avoiding costly waste.

Impact of a Prospective-Audit-With-Feedback Antimicrobial Stewardship Program at a Children's Hospital

BACKGROUND

The emergence of antibiotic-resistant organisms and the lack of development of new antimicrobials have made it imperative that additional strategies be developed to maintain the effectiveness of these existing antibiotics. The objective of this study was to describe the impact of a prospective-audit-with-feedback antimicrobial stewardship program (ASP) on antibiotic use in a children's hospital.

METHOD

A quasi-experimental study design with a control group was performed to assess the impact of a prospective-audit-with-feedback ASP. The control group was the combined antibiotic use at 25 similar children's hospitals that are members of the Child Health Corporation of America.

RESULTS

The ASP reviewed 10 460 broad-spectrum or select antibiotics in 8765 patients in the 30 months following the intervention. The most common select antibiotics reviewed were ceftriaxone/cefotaxime (43%), vancomycin (18%), ceftazidime (12%), and meropenem (7%). A total of 2378 recommendations were made in 1703 (19%) patients; the most common recommendation was to stop antibiotics (41%). Clinicians were compliant with agreed-upon ASP recommendations in 92% of patients. When comparing our antibiotic use with that of the control group, a monthly decline in all antibiotics of 7% (P = .045) and 8% (P = .045) was observed for days of therapy (DoT) and length of therapy (LoT) per 1000 patient-days, respectively. An even greater effect was observed in the select antibiotics as the monthly DoT per 1000 patient-days declined 17% (P < .001) and the monthly LoT per 1000 patient-days declined 18% (P < .001).

CONCLUSIONS

A prospective-audit-with-feedback ASP can have a significant impact on decreasing antibiotic use at a children's hospital.

Projecting future drug expenditures--2012

PURPOSE

Factors likely to influence drug expenditures, drug expenditure trends in 2010 and 2011, and projected drug expenditures for 2012 are discussed.

SUMMARY

Data were analyzed to provide drug expenditure trends for total drug expenditures and the hospital and clinic sectors. Data were obtained from the IMS Health National Sales Perspectives database. From 2009 to 2010, total U.S. drug expenditures increased by 2.7%, with total spending rising from $299.2 billion to $307.5 billion. Drug expenditures in clinics grew by 6.0% from 2009 to 2010. Hospital drug expenditures increased at the moderate rate of 1.5% from 2009 to 2010; through the first nine months of 2011, hospital drug expenditures increased by only 0.3% compared with the same period in 2010. The dominant trend over the past several years is substantial moderation in expenditure growth for widely used drugs, primarily due to the ongoing introduction and wide use of generic versions of high-cost, frequently used medications. At the end of 2010, generic drugs accounted for 78% of all retail prescriptions dispensed. Another pattern is substantial increases in expenditures for specialized medications, particularly in the outpatient setting as growth in prescription drug expenditures for clinic-administered drugs consistently outpaces growth in total expenditures. Various factors are likely to influence drug expenditures in 2012, including drugs in development, the diffusion of new drugs, generic drugs, drug shortages, and biosimilars.

CONCLUSION

For 2012, we project a 3-5% increase in total drug expenditures across all settings, a 5-7% increase in expenditures for clinic-administered drugs, and a 0-2% increase in hospital drug expenditures.

Forecasting drug utilization and expenditure in a metropolitan health region

BACKGROUND

New pharmacological therapies are challenging the healthcare systems, and there is an increasing need to assess their therapeutic value in relation to existing alternatives as well as their potential budget impact. Consequently, new models to introduce drugs in healthcare are urgently needed. In the metropolitan health region of Stockholm, Sweden, a model has been developed including early warning (horizon scanning), forecasting of drug utilization and expenditure, critical drug evaluation as well as structured programs for the introduction and follow-up of new drugs. The aim of this paper is to present the forecasting model and the predicted growth in all therapeutic areas in 2010 and 2011.

METHODS

Linear regression analysis was applied to aggregate sales data on hospital sales and dispensed drugs in ambulatory care, including both reimbursed expenditure and patient co-payment. The linear regression was applied on each pharmacological group based on four observations 2006-2009, and the crude predictions estimated for the coming two years 2010-2011. The crude predictions were then adjusted for factors likely to increase or decrease future utilization and expenditure, such as patent expiries, new drugs to be launched or new guidelines from national bodies or the regional Drug and Therapeutics Committee. The assessment included a close collaboration with clinical, clinical pharmacological and pharmaceutical experts from the regional Drug and Therapeutics Committee.

RESULTS

The annual increase in total expenditure for prescription and hospital drugs was predicted to be 2.0% in 2010 and 4.0% in 2011. Expenditures will increase in most therapeutic areas, but most predominantly for antineoplastic and immune modulating agents as well as drugs for the nervous system, infectious diseases, and blood and blood-forming organs.

CONCLUSIONS

The utilisation and expenditure of drugs is difficult to forecast due to uncertainties about the rate of adoption of new medicines and various ongoing healthcare reforms and activities to improve the quality and efficiency of prescribing. Nevertheless, we believe our model will be valuable as an early warning system to start developing guidance for new drugs including systems to monitor their effectiveness, safety and cost-effectiveness in clinical practice.

Pro/con debate: Should antimicrobial stewardship programs be adopted universally in the intensive care unit?

You are director of a large multi-disciplinary ICU. You have recently read that hospital-wide antibiotic stewardship programs have the potential to improve the quality and safety of care, and to reduce the emergence of multi-drug resistant organisms and overall costs. You are considering starting one of these programs in your ICU, but are concerned about the associated infrastructure costs. You are debating whether it is worth bringing the concept forward to your hospital's administration to consider investing in.

Allocating cancer-directed expenditures: tensions between prevention, early detection and treatment is unnecessary

In most countries, the allocation of financial resources for cancer prevention, early detection, and treatment come from different nonrelated "silos." Primary prevention benefits have the greatest economic return since the cancer benefits are intertwined with other major health conditions. Smoking alone accounts for about one-third cancer deaths. In most affluent countries, vaccines for selected viral caused cancers are (wisely) widely available if not optimally utilized. Estimating the additional cancer burden from obesity is still evolving. Age-targeted, less frequent but higher rates of participation in early detection of cervical, breast, and colorectal cancer will likely be prudent expenditures.The last 20 years in high-income countries, there has seen an explosion in demand and the costs of cancer drug or biologic therapy, a modest growth in some forms of radiation, yet minimal or declining surgical costs for primary disease control. Expenditures for cancer drugs are now the world leader of any medication category. While a few have truly led to marked benefits, all have been priced at levels that strain or break budgets. We comment on ten steps or principles that can be applied in most countries that can meaningfully reduce cancer care costs with minimal impact on survival and maintain or enhance quality of patient's life especially with advanced disease. We emphasize limiting systemic therapies for metastatic disease to fully ambulatory patients, those who previously responded to therapy, and earlier initiation of palliative care. Changing behaviors, incentives, expectations, and the framing of treatment effects are necessary to "bend" the current unrelenting cancer care cost curve.

Industry Relationships and the Pharmacy Director: Striking the Right Balance

The Director's Forum series is written and edited by Michael Sanborn and Robert Weber and is designed for guiding pharmacy leaders in establishing patient-centered services in hospitals and health systems. Another specific goal of this column is addressing many of the key challenges that pharmacy directors currently face, while also providing information that will foster growth in pharmacy leadership and patient safety. Recent public highlight of inappropriate relationships between health care professionals and the industry requires that the pharmacy director actively promote an environment of unbiased practice. The article features ways the pharmacy director can further recognize and react to potential workplace conflicts of interest.

American Society of Clinical Oncology Guidance Statement: The Cost of Cancer Care

Advances in early detection, prevention, and treatment have resulted in consistently falling cancer death rates in the United States. In parallel with these advances have come significant increases in the cost of cancer care. It is well established that the cost of health care (including cancer care) in the United States is growing more rapidly than the overall economy. In part, this is a result of the prices and rapid uptake of new agents and other technologies, including advances in imaging and therapeutic radiology. Conventional understanding suggests that high prices may reflect the costs and risks associated with the development, production, and marketing of new drugs and technologies, many of which are valued highly by physicians, patients, and payers. The increasing cost of cancer care impacts many stakeholders who play a role in a complex health care system. Our patients are the most vulnerable because they often experience uneven insurance coverage, leading to financial strain or even ruin. Other key groups include pharmaceutical manufacturers that pass along research, development, and marketing costs to the consumer; providers of cancer care who dispense increasingly expensive drugs and technologies; and the insurance industry, which ultimately passes costs to consumers. Increasingly, the economic burden of health care in general, and high-quality cancer care in particular, will be less and less affordable for an increasing number of Americans unless steps are taken to curb current trends. The American Society of Clinical Oncology (ASCO) is committed to improving cancer prevention, diagnosis, and treatment and eliminating disparities in cancer care through support of evidence-based and cost-effective practices. To address this goal, ASCO established a Cost of Care Task Force, which has developed this Guidance Statement on the Cost of Cancer Care. This Guidance Statement provides a concise overview of the economic issues facing stakeholders in the cancer community. It also recommends that the following steps be taken to address immediate needs: recognition that patient-physician discussions regarding the cost of care are an important component of high-quality care; the design of educational and support tools for oncology providers to promote effective communication about costs with patients; and the development of resources to help educate patients about the high cost of cancer care to help guide their decision making regarding treatment options. Looking to the future, this Guidance Statement also recommends that ASCO develop policy positions to address the underlying factors contributing to the increased cost of cancer care. Doing so will require a clear understanding of the factors that drive these costs, as well as potential modifications to the current cancer care system to ensure that all Americans have access to high-quality, cost-effective care.

Ordering Off the Menu: Assessing Compliance with a Nonformulary Medication Policy

Background:

Use of nonformulary medications (NFMs) may create added costs and potential safety issues. Institutional policies can support compliance with formulary systems and address these issues. However, periodic review is needed to assess the effectiveness of NFM policies.

Objective:

To evaluate NFM use at a large university medical center and assess for compliance with the established policy as well as for prescribing errors, procurement procedures, and delivery times.

Methods:

All new medication orders entered as NFM in the computerized order entry system during a 6-week period were evaluated and followed until administration of the first NFM dose. Orders were categorized as NFMs, formulary medications (FMs), or the patient's own medications. Each order was evaluated to determine the prescriber, service and location of the patient, and any prescribing errors. Additional information, such as the indication, location where the medication was obtained, and the delivery time, was obtained through patient chart review and the pharmacist intervention database.

Results:

A total of 237 orders were entered as nonformulary; 72 (30%) were FMs and 165(70%) were NFMs. Of the 165 NFM orders, 71 (43%) were orders for the patient's own medication. Of the remaining 94 NFMs, only 39% met the institution's established policy criteria. Overall, 28% of all orders entered as nonformulary had a prescribing error. Of these, 49% were incorrect dosages and 33% were misspelled orders. Seventy percent of NFMs were obtained from the institution's standard locations. The institution's nonformulary turnaround time was achieved with 96% of NFMs.

Conclusions:

The majority of NFM orders did not meet the institution's established criteria and these orders frequently contained prescribing errors. Routine assessment of NFM use and policy compliance can present opportunities for improvement.

Establishing a Plan for Central Pharmacy Automation

The Director's Forum series is written and edited by Michael Sanborn and Robert Weber and is designed for guiding pharmacy leaders in establishing patient-centered services in hospitals and health systems. Another specific goal of this column is addressing many of the key challenges that pharmacy directors currently face, while also providing information that will foster growth in pharmacy leadership and patient safety. Previous Director's Forum articles have discussed various aspects of pharmacy technology implementation and utilization. This feature reviews the steps and strategies for implementing and evaluating automation in a central pharmacy area supporting a decentralized pharmaceutical model.