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Models for Effective Medication

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					Models for Effective Medication
Use in Health Care Systems




     Susan J. Curry, Ph.D.
     University of Illinois at Chicago
Models for effective medication use in
 health care systems for treatment of
 tobacco use and dependence should be
 consistent with models for treatment of
 other chronic conditions
     Chronic Care Model
                                       Health System
                                   Health Care Organization
   Community
Resources and          Self-       Delivery                   Clinical
                    Management     System       Decision    Information
Policies                                        Support
                     Support       Design                     Systems




                Informed,         Productive          Prepared,
                Activated                             Proactive
                 Patient
                                 Interactions
                                                    Practice Team




                  Functional and Clinical Outcomes
Medication can be used effectively if
 it is:
  Available
  Affordable
  Appealing
  Appropriately used
Making Medications Available:
Formulary Decisions

Prescription drug costs up 19% in 2000
  36% of increase due to new, >$ drugs
  higher drug costs not offset by lower medical
   costs
Insurers & MCOs control costs and
 outcomes by making evidence-based
 decisions on whether to place new drugs
 on formulary
Formulary decisions

Focus on clinical outcomes as well as
 economics
Made by committee
Use standardized guidelines
  Regence BlueShield Formulary
  Guidelines

  Regence clinical pharmacists complete
   detailed review of each drug based on
   clinical literature.
  Medical literature on efficacy,
   effectiveness and relative safety is
   foundation for formulary review
  FDA “AB” rated generics will generally be
   preferred
Mather et al, A J Man Care, 1999;5(3):277-285
  Regence BlueShield Formulary
  Guidelines

  Brand names only included when offer
   value (e.g., significantly more clinically
   effective than generics or other brands in
   the same therapeutic class)
  When clinical studies show that several
   drugs are clinically equivalent, only the
   products with the lowest net cost will be
   included in the formulary
Mather et al, A J Man Care, 1999;5(3):277-285
  Regence BlueShield Formulary
  Guidelines

  Improved dosage forms only considered
   when their cost effectiveness can be
   documented
  For each drug, manufacturers are required
   to submit dossiers that include detailed
   clinical and economic information,
   including data from published and
   unpublished studies, and outcomes
   modeling
Mather et al, A J Man Care, 1999;5(3):277-285
  Regence BlueShield Formulary
  Guidelines

  Economic modeling will be used to
   evaluate the impact of each drug on
   patients‟ clinical outcomes, medical
   claims, and costs of care.




Mather et al, A J Man Care, 1999;5(3):277-285
Formulary decisions
bottom line

„Burden of proof‟ is on the medication
 (and, by extension the manufacturer)
As number and types of
 pharmacotherapies for tobacco use
 cessation increases there will be
 increasing demand from health systems
 for data on their relative clinical and cost
 effectiveness
Making medications affordable:
Insurance coverage

Use goes up with full coverage
  25% vs. 14% used NRT over 12 months
   (Schauffler et al, Tob Cont, 2001)

But not always…
  19% vs. 24% used Zyban
  28% vs. 26% used NRT over 12 months
   (Boyle et al, Health Affairs, 2002)
Making medications affordable:
Insurance coverage

The more it costs, the less it‟s used
  50% co-payment on NRT associated with
   31% drop in use (Curry et al, NEJM, 1998)
Many with coverage don‟t know they have
 it
  30% in Boyle study knew of coverage
  Use of medications higher if aware of
   coverage (42% Zyban; 31% NRT)
Making medications affordable:
Insurance coverage

How benefit is structured can impact
 availability and use of new medications
  Bundled with behavioral program
  Coverage for specific medications or all FDA-
   approved
  Amount dispensed per prescription
Making pharmacotherapy
appealing

Does prior failure with pharmacotherapy
 reduce demand for new treatment?
  National data not available, but RTC data
   suggest not
    Over 60% of volunteers for Zyban effectiveness
     trial had prior use of NRT
  Pharmacotherapy may have inherent appeal
   to smokers looking for the „magic bullet‟
Making pharmacotherapy
appealing

Pharmaceuticals‟ investments
  Direct-to-consumer marketing
  Academic detailing for clinicians
Health care system investments
  vital sign stamps, chart stickers for easy
   identification of smokers
  medical record prompts for advice, assistance
  clinical information systems and registries for
   follow-up
Facilitating appropriate use

Medication approval in efficacy trials
  face-to-face prescribing
  regular monitoring & behavioral support
Medication use in effectiveness conditions
  over-the-phone prescriptions
  under-dosing (amount &/or duration)
  concurrent smoking
  no behavioral support
Facilitating appropriate use:
Behavioral support

Bundled coverage ensures behavioral
 support
Seamless protocols for obtaining
 pharmacotherapy as part of behavioral
 program ensures medication use
  Facilitating appropriate use:
  Behavioral support

  Integrated Model*
       Telephone-based enrollment & screening for
        medication eligibility
            case review for questionable, ineligible by
             program physicians
            notification of potential medication use to
             patient‟s primary care provider
       Medications and written behavioral program
        materials sent by mail

*From Swan, McAfee, Curry et al, Arch Int Med (in press)
Facilitating appropriate use:
Behavioral support

Integrated model, cont‟d
  Patient enrolled in state of the art telephone
   counseling program
   (4 outreach calls over 6 months; access to
   toll-free quitline for 1 year)
  Treatment progress reports sent to primary
   care physicians
 Facilitating appropriate use:
 Behavioral support

   Free & Clear          Free & Clear   ZAP         ZAP
   150 mg                300 mg         150 mg      300 mg
   Bupropion             Bupropion      Bupropion   Bupropion


   31.4                  33.2           23.6        25.7




Dose OR    = 1.05 [0.94,1.17]
Program OR = 1.21 [1.08,1.35]
Moderate intensity behavioral programs
 do improve long-term outcomes
Can be provided „in-house‟ or through
 linkages with community-based programs
 (e.g., state quit-lines)
Re-cap

Medications must be available
  May be a higher bar for new medications
Affordability is important
  Particularly for lower income smokers where
   prevalence is increasingly concentrated
Chronic disease care models in health
 care systems are appropriate
  Behavioral (self-management) support is a
   key component

				
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posted:2/28/2010
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