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PubMed2005

Factors that influence prescribers in their selection and use of COX-2 selective inhibitors as opposed to non-selective NSAIDs.

OBJECTIVE: To identify factors that influence prescribers in their selection and use of cyclo-oxygenase-2 (COX-2) selective inhibitors as opposed to non-selective non-steroidal anti-inflammatory drugs (NSAIDs) and report the tendency to co-prescribe gastro-protection with these agents. SETTING: All 579 general practitioners (GPs) in one geographical area, Lothian, Scotland, UK. METHOD: Postal questionnaires; simple and factorial designed case series questionnaire. MAIN OUTCOME MEASURES: Categorisation of responses to clinical and non-clinical factors into highly, partially or not influential. The quantitative influence of the most prominent clinical factors on prescribing choice and the tendency of co-prescription of gastro-protection with these agents. RESULTS: Responses from 229 (40%) GPs suggested the following as most influential: Drug Evaluation Panel recommendations, Lothian Joint Formulary, local practice formulary, history of peptic ulcer disease (PUD), history of gastro-intestinal (GI) adverse effects with NSAIDs and advanced age. Advice from other physicians, patient demand, history of alcohol gastritis, history of gastro-oesophageal reflux disease, history of functional dyspepsia, concomitant use of low dose aspirin and concomitant use of gastro-protective agents were regarded to have moderate influence. Information directly from pharmaceutical industry and regular smoking were regarded as having weak influence. An 18% response to the factorial designed questionnaire using the most prominent clinical factors suggested that history of either GI adverse effects associated with non-selective NSAIDs or PUD resulted in more pronounced increase in the frequency (15%) of decision to prescribe COX-2 selective inhibitors than advanced age (10%). Concomitant use of low dose aspirin had little effect on GPs' decisions. The mean percentage of GPs choosing to co-prescribe gastro-protection was higher with non-selective NSAIDs (64%) than with COX-2 selective inhibitors (22%). CONCLUSION: Local authoritative guidance and history of GI complications highly influenced the GPs in their use and choice of either COX-2 selective inhibitors or non-selective NSAIDs. As expected the use of gastro-protection was more frequently chosen with non-selective NSAIDs than COX-2 selective inhibitors.

Age Factors↗
PubMed2006

Ethical principles for psychiatric administrators: the challenge of formularies.

Rising costs continue to plague healthcare and mental healthcare. The latest variation of managed care techniques has been to try to reduce medication costs by instituting formulary restrictions. To date, the results have been spotty at best, with a suggestion of a ballooning of more general mental healthcare costs, as well as possibly worsening of quality of care. New challenges are looming in terms of the results of the CATIE study comparing typical and atypical antipsychotic medication, as well as the beginning of Medicare D medication coverage. In the midst of the uncertainty and complexity, the psychiatrist administrator has the ethical challenge and chance to make a major difference. By keeping the well-being of patients first, but also addressing the needs of the institution, payor, and other stakeholders, the psychiatrist administrator can ethically find ways to reduce costs and increase quality. One such product could be medication algorithms that also incorporate costs, side effects, and general healthcare.

Antipsychotic Agents↗
PubMed1994

Cost-effectiveness considerations for managed care systems: treating depression in primary care.

This article addresses the management of depression in primary care from the perspective of a health maintenance organization. The rise of managed care systems is briefly discussed with reference to their impact on choice of treatment strategies. Cost-effectiveness considerations pertinent to a health maintenance organization are reviewed. A simplified protocol for the treatment of depression with paroxetine or imipramine in the primary care sector is presented and used as an example of cost calculations. Given the assumptions used in this cost-effectiveness model, it appears that the costs of treating depression in primary care with paroxetine are approximately equal to those found with the use of imipramine. Higher acquisition costs of paroxetine are balanced by the greater labor costs associated with imipramine.

Cost-Benefit Analysis↗
PubMed1993

The way to economic prescribing.

Concern about the size of the NHS drugs bill in the UK has resulted in three main policy initiatives by government: regular increases in prescription charges, the introduction of restrictions on the range of prescribable drugs, and the implementation of prescribing budgets. This paper argues that such policies, whilst reducing the NHS drugs bill, have given little consideration to the efficiency of prescribing. Other policy options are considered which may reduce the NHS drugs bill in ways more consistent with efficient prescribing.

Budgets↗
PubMed1985

The social drug lag: an examination of pharmaceutical approval delays in Medicaid formularies.

Several states have enacted restrictive drug formularies in order to control the costs of their Medicaid pharmaceutical programs. This study investigates the restrictiveness of these formularies by analyzing the delay in approving new drug products for Medicaid reimbursement. A restrictiveness index is developed which relates the drug product months which are denied to Medicaid patients to the potential product months of availability if all products which were newly approved for general use were simultaneously made available to the Medicaid population. The study then relates the restrictiveness of state formularies to Medicaid drug program costs and to total Medicaid program costs. We find that restrictiveness of formularies is not associated with lower drug costs, but that total Medicaid costs are lower in states with more restrictive formularies. We suggest that restrictive formularies may occur in states with other Medicaid cost-containment measures, so that total Medicaid expenditures are contained in those states, even though there is no reduction in drug expenditures.

Cost Control↗
PubMed1993

A veterinary antibiotic policy: a personal view on the perspectives in The Netherlands.

To reach a more adequate and responsible use of antibiotics in veterinary medicine a broad approach is required. The growing interest in the optimum use of antibiotics in veterinary medicine is stimulated by awareness of the necessity to prevent the emergence of resistance and the spread of resistant bacteria. This is a matter of primary importance to safeguard the efficacy of antibiotic therapy in animals now and in the future, but will also minimise possible public health risks. As resistance develops in rough relation to antibiotic use, the best way to minimise emergence of resistance, without interfering with optimal veterinary care, is to rationalize the use of antibiotics by, or under responsibility of, a veterinary surgeon. A second further improvement can be reached by developing a veterinary antibiotic policy to prevent emergence and spread of resistance as much as possible. Measures that must be taken in combination are: 1. Establishing a policy for the use of antibiotics jointly by veterinary practitioners and experts resulting in a formulary. 2. Systemic registration and analysis of patterns of bacterial resistance (not only of pathogens but of faecal flora as well) and the use (qualitative and quantitative) of antibiotics in veterinary medicine. 3. Regular feedback of these data to the veterinary practitioners and consultation about the efficacy of the formulary guidelines in daily practise. 4. Systemic monitoring and evaluation the impact of the antibiotic policy and, if indicated, updating of the formulary. 5. Continuous education of veterinary surgeons about infectious diseases and antimicrobial therapy and development of a veterinary audit system. The first step to rationalize the veterinary use of antibiotics was taken by publishing a veterinary antibiotic formulary in 1987, compiled by a group of experts. Despite the fact that this was a pure top down approach and bottom up input from veterinary practitioners was lacking, this first formulary was very well received. However the impact of this formulary on the veterinary use of antibiotics and prevalence of resistance has not been evaluated at this moment. Until now regular and nationwide systemic monitoring of resistance and registration of veterinary use of antibiotics is not practically feasible in the Netherlands. A new formulary, based on a veterinary antibiotic will be published by the end of 1992. However, to be able to evaluate the impact of this policy on the prevalence of resistance and, if necessary, to adapt the policy the development of facilities for resistance epidemiology is urgently needed.

Animals↗
PubMed2004

Knowledge modeling and acquisition of traditional Chinese herbal drugs and formulae from text.

Traditional Chinese medicine has developed over more than 4000 years. A tremendous amount of medical knowledge has been accumulated, among which herbal drugs and formulae are an important portion. This paper presents an ontology for traditional Chinese drugs and formulae, and an ontology-based system for extracting knowledge of drugs and formulae from semi-structured text. The system consists of two components: an executable knowledge extraction language (or EKEL) for specifying knowledge-extracting agents, and a support machine for executing EKEL programs. Experiments show that the system is adequate of extracting knowledge of herbal drugs and formulae from semi-structured text.

Automation↗
PubMedDate not supplied

Psychotropic drug versus psychotropic drug-update.

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).

Drug Interactions↗
PubMed2004

The effect of generic competition on the price of brand-name drugs.

BACKGROUND: Literature from the US has shown that brand-name manufacturers do not compete on price once generic competitors become available. This study was undertaken to investigate if this is also true in Canada. METHODS: Editions of the Ontario Drug Benefit Formulary were used to identify brand-name drugs that lacked generic competition in July 1990 but had acquired one or more generic competitors by December 1998. Prices of the brand-name drugs were compared before generic competition, at the point when generic competition started and subsequent to the initiation of competition. RESULTS: Price changes for 81 different products in 144 separate presentations were analysed. There was no statistically significant change in brand-name prices when generic competition started. The movement of brand-name prices was not influenced by whether the generic was made by the company producing the brand-name product or price freezes imposed by the Ontario government. When generics first became available having four or more generics was associated with a rise in the price of the brand-name drugs compared to having one, two or three generic competitor(s). INTERPRETATION: The lack of price competition may lead to increased costs in the private market. Private insurance companies generally do not require generic substitution and some provinces do not require generic substitution for cash-paying customers. Maintaining higher prices on brand-name drugs impacts on the prices of new patented medications coming onto the Canadian market under the current pricing guidelines of the Patented Medicine Prices Review Board.

Drug Costs↗
PubMed2005

Judgment processes in older adults' drug benefit evaluations.

BACKGROUND: The Medicare Prescription Drug, Improvement and Modernization Act of 2003 will provide drug coverage to older adults through a variety of mechanisms, including stand-alone prescription drug benefits. Variation in cost-sharing and utilization controls is permitted, leading potentially to a wide variety of prescription benefit plans. However, little is known regarding the manner in which beneficiaries will integrate information to form plan evaluations. OBJECTIVES: The objectives of this study were to assess and compare the use of compensatory and configural judgment models in older adults' evaluations of drug benefit plans. METHODS: Three focus groups were conducted with a total of 19 seniors to elicit relevant drug plan attributes. A separate group of 32 seniors then judged the suitability of 48 drug benefit profiles based on these attributes. Within-subjects regression analysis was used to reveal each participant's judgment policy. RESULTS: Focus groups suggested that copayment, premium, deductible, formulary use, and mail-service use were relevant plan attributes. Regression analyses showed that while most participants used compensatory judgment models in evaluation formation, 12 (37.5%) subjects used conjunctive judgment models. CONCLUSIONS: Configural judgment processes are used frequently by older adults when evaluating drug benefit plans. Future research using more fine-grained techniques (eg, process tracing) might help further elucidate judgment processes in this context.

Aged↗
PubMed2005

Use of health-related quality of life information in managed care formulary decision-making.

BACKGROUND: The extent to which the increased volume of available health-related quality of life (HRQOL) information and heightened education has increased the acceptance and use of HRQOL remains unclear. Likewise, the value of HRQOL information in the formulary decision-making process continues to be undefined. OBJECTIVE: To investigate the perceptions and use of HRQOL by managed care decision-makers in the formulary development process. METHODS: A mail survey was sent to a nationwide sample of 108 Academy of Managed Care Pharmacy (AMCP) members who were involved in formulary management. Survey candidates were identified according to their job titles listed in the 1999-2000 AMCP membership directory. The survey process began in May 2000 and ended in August 2000. The main outcome measures included (a) managed care formulary decision-makers' assessment of HRQOL as a treatment outcome, (b) the existing role and future use of HRQOL information in formulary decisions, and (c) the level of understanding of HRQOL concepts and the benefits attributable to favorable HRQOL results. RESULTS: A response rate of 51.9% was obtained. Most of the respondents (>70%) believed that patients consider HRQOL as an important treatment outcome. Fewer respondents (43%) felt that payers view HRQOL outcomes as an important quality indicator. Most respondents (95%) considered HRQOL data in making formulary decisions, and many (73%) believe that HRQOL outcomes will play a more important role in future formulary decisions. Respondents indicated a better understanding of disease-specific and generic HRQOL measurements than utility measurement and interpretation of results. A minority of respondents (34%) would be willing to pay a higher price for a product with better HRQOL outcomes. When asked which factors would lead to increased use of HRQOL information, respondents indicated that health care cost savings and increased productivity were considered important (77% and 65%, respectively). CONCLUSIONS: A drug product with better HRQOL outcomes alone will not command a favorable listing on managed care formularies. HRQOL information needs to be made more applicable to managed care decision-making. Future studies should focus on the link between positive HRQOL outcomes, health care cost savings, and increased productivity.

Adult↗
PubMed2006

Centralized drug review processes: are they fair?

Numerous countries have implemented centralized drug review processes to assist in making drug coverage decisions. In addition to examining the final recommendations of these bodies, it is also important to ensure fairness in decision making. Accountability for reasonableness is an ethics-based framework for examining the fairness of priority setting processes. The objective of this study was to assess the fairness of four internationally established centralized drug review processes using accountability for reasonableness. Semi-structured telephone interviews were conducted with stakeholders in Canada, New Zealand, Australia and the UK (n=16). Participants were asked to evaluate their country's centralized drug review process against the four conditions of accountability for reasonableness. Each centralized drug review process satisfied at least one of the four ethical conditions, but none satisfied all four conditions. All participants viewed transparency as critical to both the legitimacy and fairness of centralized drug review processes. Additional strides need to be made in each of the four countries under study to improve the fairness of their centralized drug review processes. Ideally, a fair priority setting process should foster constructive stakeholder engagement and enhance the legitimacy of decisions made in assessing pharmaceutical products for funding. As policy makers are under increasing scrutiny in allocating limited resources, fair process should be seen as a critical component of such activity. This study represents the first attempt to conduct an international comparison of the fairness of centralized drug review agencies in the eyes of participating stakeholders.

Australia↗
PubMed2006

The role of law in public health: the case of family planning in the Philippines.

Compared to neighboring countries, the Philippines has high fertility rates and a low prevalence of modern-method contraception use. The Philippine government faces political and cultural barriers to addressing family planning needs, but also legal barriers erected by its own policies. We conducted a review of laws and policies relating to family planning in the Philippines in order to examine how the law may facilitate or constrain service provision. The methodology consisted of three phases. First, we collected and analyzed laws and regulations relating to the delivery of family planning services. Second, we conducted a qualitative interview study. Third, we synthesized findings to formulate policy recommendations. We present a conceptual model for understanding the impact of law on public health and discuss findings in relation to the roles of health care provider regulation, drug regulation, tax law, trade policies, insurance law, and other laws on access to modern-method contraceptives.

Contraception↗
PubMed2004

Assessing the impact of wastage on pediatric vaccine immunization formulary costs using a vaccine selection algorithm.

Pediatric immunization is an important factor in providing protection against numerous common preventable diseases. The success of the pharmaceutical industry in developing new pediatric vaccines has resulted in a crowded recommended immunization schedule requiring several clinic visits over the first 12 years of life. Operations research models have been developed and used to make economically sound procurement choices from among a growing number of competing vaccine products. One factor that has not been incorporated into such models is the economic impact of wastage on such decisions. This paper reports results obtained from a vaccine selection algorithm that incorporates vaccine wastage data. The lowest overall cost formularies comparing no wastage costs with wastage costs are presented. A sensitivity analysis of the vaccine formulary with respect to the wastage rates associated with each available vaccine is provided. The maximum permissible wastage rate for each vaccine is determined for which the vaccine earns a place in the lowest overall cost formulary. This research provides health maintenance organizations and healthcare providers information that can be used to gain a better understanding of wastage and its impact on pediatric formulary costs.

Algorithms↗