Transcript Outcomes & Cost Management in Pharmacy Practice Slide

Pharmacy 483
Outcomes & Cost Management
in Pharmacy Practice
Janet Kelly, Pharm.D., BC-ADM
February 24, 2004
Health Care Cost Over Time
% Increase in Cost
20.0
15.0
10.0
5.0
0.0
Years (1990- 2001)
Hospital
Physician
Medication
Factors Contributing to
Increasing Medication Costs
6.8%
8.1%
4.1%
Increased Utilization
Inflation
New Medications
Clinical
Pharmacists
Outcomes &
Cost
Management
Formulary
Management
Providers
(RN, MD, etc)
What is a Drug Formulary?
 List of Drugs Which May Be Prescribed
Developed by the P&T Committee based on:
 Efficacy
 Safety
 Cost Effectiveness
 Therapeutic Equivalency
 Treatment Guidelines
How Can a Formulary Optimize
Outcomes & Costs?
 Standardization of Care
 Appropriate Utilization
 Improved Safety
 Less Potential for Errors
 Bulk Purchasing
 Contract Pricing
Role of Clinical Pharmacists in
Outcomes & Cost Management
 Identification
 Reality Check
 Expertise
 Implementation
Therapeutic Equivalency
UW Medicine Example: 5HT3 Antagonists
Ondansetron
(Zofran)
Dolasetron
(Anzemet)
Granisetron
(Kytril)
Equipotent Dosing
IV Dosing
Ondansetron
8mg
=
Dolasetron
100mg
=
Dolasetron
100mg
=
Granisetron
1mg
=
Granisetron
2mg
Oral Dosing
Ondansetron
16mg
Treatment Guidelines
For Chemotherapy Induced Nausea/Vomiting
Emetogenic Potential
Treatment Guidelines
MINIMAL
No treatment necessary
MODERATE
Ondansetron 16 mg po or 8 mg IV X1
Dexamethasone 20 mg po or IV X1
Lorazepam 1-2 mg po X1
HIGH
Ondansetron 24 mg po or 8 mg IV X1
Dexamethasone 20 mg po or IV X1
Lorazepam 1-2 mg po X1
Cost Savings Associated with the
5HT3 Program at UW Medicine
Annual Acquisition Cost
2,500,000
2,000,000
1,500,000
1,000,000
500,000
2002
UWMC
2003
SCCA
HMC
UW Medicine
Net Savings = $534,000
New Drug Evaluation for Formulary
CLINICAL EFFICACY
1. Therapeutically superior to current formulary options
2. Effective for the treatment of condition which
previously had no effective therapy
SAFETY
1. Improved safety and/or tolerability compared
to current therapeutic options while maintaining
therapeutic effectiveness
COST EFFECTIVENESS
1. Offers cost advantages to the institution for a given
outcome compared to current formulary options
How is Cost Effectiveness Defined?
Therapeutic Outcomes
&
Economic Evaluation
=
Cost Per Outcome
Steps in an Economic Evaluation
1. Determination of Total Cost
2. Determination of Reimbursement
3. Calculation of Potential Revenue
Darbepoetin:
Formulary Evaluation
Clinical Evaluation (compared to Epoetin)
Similar efficacy with less frequent dosing
? Equivalent dosing
? Dose escalation
Similar safety
? Improved compliance
Economic Evaluation of Darbepoetin
Determination of Costs:
Drug Acquisition
Convenience
Rebates and Incentives for
Other Amgen Products
Less frequent administration
Dollar Value ?
Drug Administration Cost
Clinic vs. Self Administered
Economic Evaluation of Darbepoetin
Determination of Reimbursement:
Ambulatory
vs.
Hospitalized
Insurance Mix
% Medicare, Medicaid, & Private
Patient Responsibility
Co-pays
Economic Evaluation of Pegfilgrastim
Calculation of Profit Margin:
-
=
Reimbursement
Profit Margin
Total Cost
UW Medicine
Clinical Pathway for Darbepoetin for Anemia of CRI
Hgb<11 g/dL
Check nutritional cofactors
GOALS OF DARBEPOETIN THERAPY
Previously untreated pts
0.9
0.9 mcg/kg
mcg/kg qq 22 weeks*
weeks
Resolution of Anemia : Hgb=12 g/dL
2 week Follow Up
Has Hgb Increased > 1g/dl over baseline?
Yes
No
Decrease Dose by 25%
Supplement with iron if:
1.
Serum ferritin<100 mg/ml
2.
Transferrin saturation<20%
Continue Therapy
NO DOSE INCREASE
6 week Follow Up
Has Hgb> 1g/dl from baseline?
Yes
No
Recheck nutritional cofactors
Continue Therapy
If Hgb>12
decrease dose to next vial size
Increase dose to next vial size
Maximum of 200 mcg q 2 weeks
UW Medicine – Clinical Pathway
for Darbepoetin use in Chemotherapy Induced Anemia
Hgb<11 g/dL
GOALS OF DARBEPOETIN THERAPY
Resolution of Anemia : Hgb>12 g/dL
Starting Dose:
200 mcg q2 wk or 300 mcg q 3wk
Reduced need for transfusion
6 week Follow Up
2
Has Hgb Increased > 1g/dl over baseline?
Yes
No
Supplement with iron if:
1.
Serum ferritin<100 mg/ml
2.
Transferrin saturation<20%
Recheck nutritional cofactors
Increase dose to
300 mcg q 2 wks
Continue Therapy
Yes
12
6 week
weekFollow
FollowUp
Up
Has Hgb> 1g/dl from baseline?
No
Recheck nutritional cofactors
Monitor Hgb –hold if Hgb>13
Resume Tx when Hgb<12
200 mcg q3wks
Consider discontinuing Depending on Pt’s symptomatic
response
Comparison of Cost Effectiveness
Darbepoetin vs. Epoetin
Therapeutic Outcome
Equivalent
&
Economic Evaluation
Beneficial
=
Cost Per Outcome
Decreased
Darbepoetin Added to Formulary
With Usage Guidelines
Economic Impact at 6 months:
No Absolute Cost Savings (# Pts)
Relative Cost Savings $250,000
Drug Usage Evaluation Results:
Response Rate only 61%
Inadequate Monitoring of Iron Stores
Doses given when not anemic