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.

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 $70.93, 9.5% less than the average cost in the 12-month pre-TI period ($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 $16.15 in the post-TI period compared with $12.28 PPPY in the pre-TI period, and medical office visit costs increased by 44.9% to $20.70 PPPY in the post-TI period compared with $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 $793.69 PPPY in the pre-TI period to $701.01 PPPY in the post-TI period, resulting in a net 10.0% reduction for combined statin costs and related medical costs, from $820.27 PPPY in the pre-TI period to $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.CONCLUSIONS: Total costs for medical management of dyslipidemia with statin therapy decreased following implementation of the TI intervention for atorvastatin users. An 11.7% savings in statin drug cost, before consideration of manufacturer rebate revenues, became a net savings of 10.0% after inclusion of the medical costs associated with laboratory tests and physician office visits.

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."

1997-1999. His clinical interests are in general gastroenterology, with specific areas of interest in acid-peptic diseases of the upper gastrointestinal tract and specific disease states of interest in Helicobacter pylori-induced ulcer disease and nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers.Cryer' s primary research interest has been in the pathogenesis of peptic ulcer disease.His research focus has been clinically oriented in that he has exclusively studied the pathophysiology of these processes in humans.Recent investigations have explored the mechanism of gastrointestinal toxicity of NSAIDs within the stomach and duodenum, including an evaluation of the cyclooxygenase-2-specific NSAIDs and the effects of NSAIDs in gastroesophageal reflux disease.

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.

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. OBJECTIVES: To assess the impact of a $10 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 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 per patient in 1998 to $72.68 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 PPPM in 1998 to $35.93 in 1999 (Pless than0.001), and health plan drug costs for all 8,643 members decreased by 13% from $14.93 per member per month (PMPM) in 1998 to $12.99 in 1999 (Pless than0.001). The actual average copayment increase was $7.23 (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 (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 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.

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.

The idea that outcomes associated with the provision of health care are important is not new. In the 1960s Avedis Donabedian (1) presented health outcomes as changes in health status that were attributable to antecedent health care. For many years, however, evaluations of health care focused on the structure or process of care. As health care moves into the new millennium, financing of health care is evolving from individual providers being solely responsible for patient outcomes to an environment where payers, institutions, and providers are being held accountable for quality and cost of care. As financing of health care has moved to a more centralized locus of control, evaluation of outcomes has become more feasible and desirable. In a book titled Who Shall Live, Victor Fuchs (2) discussed three factors that can be balanced in our health care system: costs, quality, and access. Over time the pendulum swings from one to another of these dimensions. If costs containment goes too far, then quality or access may suffer. Likewise, it

Objective: To determine whether the increased acquisition costs associated with the atypical antipsychotic risperidone are offset by reductions in other mental health care utilisation and expenditure.

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.

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 hearth 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 component of outcomes research will help pharmacists decide which clinical circumstances, patient characteristics, and practice settings are most suitable for particular interventions.

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.

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.

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.