Pharmaceuticals: Access, Cost, Pricing, and Directions for the Future. 13th Annual Herbert Lourie Memorial Lecture on Health Policy

Prescription drug expenditures make up less than 10 percent of total personal health care expenditures in the United States, but over the last decade the amount that Americans spend on prescription drugs has grown much faster than any other component of personal health care. For example, between 1999 and 2000, hospital care costs rose about 5 percent, physicians and clinical services 6 percent, while prescription drug expenditures climbed more than 17 percent. In dollar amounts, prescription drug expenditures doubled, from $61 billion to$122 billion, between 1995 and 2000. Is this an unwarranted expense that needs to be controlled, or does it represent increased value, as pharmaceuticals substitute for older, most costly treatments? What is the prevalence of health insurance coverage for prescription drugs, and how does this affect specific populations who have limited or no drug benefits? What are the components of drug prices? And what do we need to consider when we design health care policy? Stephen Soumerai and Patricia Danzon look at several aspects of pharmaceutical drug usage and pricing in the United States, illustrating their observations with their published research findings. They then briefly review recent legislative proposals to broaden public insurance coverage for prescription drugs and make their own policy recommendations.

History bias, study design, and the unfulfilled promise of pay-for-performance policies in health care

Recently, PCD published a longer, related article, “How Do You Know Which Health Care Effectiveness Research You Can Trust? A Guide for the Perplexed,” that was translational in nature. The article used simple graphs and easy-to-understand text—in five case studies—to illustrate how powerful biases, combined with weak study designs that cannot control for them, can yield untrustworthy research on several widespread interventions: influenza vaccination policy, health information technology, drug safety, prevention of childhood obesity and hospital safety (“mortality reduction”) programs. Since this was not a formal methods paper, the target audiences were policy makers, journalists, trainees, and the public. The primary goal was to understand how weak or strong study designs are likely to fail or succeed in controlling for these pervasive biases. At the start of that article, we promised to add to these case examples of common biases and research designs to show why “caution is needed in understanding and accepting the results of research that may have profound and long-lasting effects on health policy and clinical practice.” In this sixth case study, the authors revisit one of the most common and virulent biases, threats of history. Studies can mislead policymakers and clinicians because they fail to control for history, which represents pre-existing or co-occurring changes in study outcomes that were happening with or without the intervention. The policy in this case, pay-for-performance (PfP, see below), is extremely sensitive to this powerful bias because medical practice is always changing as a result of factors unrelated to a policy, such as widespread media or national guidelines supporting a life-saving treatment, e.g., beta blockers for acute MI (1). Without investigating and visualizing outcomes over time before and after a policy or intervention, it is likely that the investigators will attribute such ongoing changes to “effects” of the quality improvement policy, resulting in millions of dollars of waste implementing ineffective PfP policies worldwide

The Relationship Between Older Adults' Knowledge of Their Drug Coverage and Medication Cost Problems

To determine whether chronically ill patients have gaps in knowledge about their prescription drug coverage and establish the relationship between gaps and medication cost problems. Design : Nationwide, cross-sectional survey. Setting : Nationwide survey conducted via the Internet. Participants : Three thousand one hundred nineteen adults aged 50 and older (1,400 of whom were aged ≥65) who had prescription drug coverage and at least one chronic illness. Measurements : Patients were asked about features of their drug benefits and whether they had experienced problems due to medication costs in the prior year. Results : Twenty-five percent of respondents reported not knowing their usual prescription copayments, and 41% did not know whether there were caps on their drug coverage. Nonwhite race and lower income were independent risk factors for lack of knowledge about these aspects of pharmacy benefits. Lack of knowledge regarding the limits of coverage was associated with a greater likelihood of cutting back on medication use because of cost pressures, forgoing basic needs because of medication costs, borrowing money to pay for prescriptions, and worrying about medication costs (all P <.05). Conclusion : Many older adults with prescription drug coverage do not know important features of their pharmacy benefits. Racial minorities and those with low incomes may have the greatest difficulty understanding coverage and as a result may be at greatest risk for underusing their benefits. Education about Medicare reforms and other efforts to increase prescription coverage should accompany these policies.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66286/1/j.1532-5415.2005.00527.x.pd

Pharmaceuticals: Access, Cost, Pricing, and Directions for the Future

Prescription drug expenditures make up less than 10 percent of total personal health care expenditures in the United States, but over the last decade the amount that Americans spend on prescription drugs has grown much faster than any other component of personal health care. For example, between 1999 and 2000, hospital care costs rose about 5 percent, physicians and clinical services 6 percent, while prescription drug expenditures climbed more than 17 percent. In dollar amounts, prescription drug expenditures doubled, from $61 billion to$122 billion, between 1995 and 2000. Is this an unwarranted expense that needs to be controlled, or does it represent increased value, as pharmaceuticals substitute for older, most costly treatments? What is the prevalence of health insurance coverage for prescription drugs, and how does this affect specific populations who have limited or no drug benefits? What are the components of drug prices? And what do we need to consider when we design health care policy? Stephen Soumerai and Patricia Danzon look at several aspects of pharmaceutical drug usage and pricing in the United States, illustrating their observations with their published research findings. They then briefly review recent legislative proposals to broaden public insurance coverage for prescription drugs and make their own policy recommendations

Effect of changes in antibiotic prescribing on patient outcomes in a community setting: A natural experiment in Australia

© 2002 by the Infectious Diseases Society of America.This study examined whether a significant change in antibiotic use caused by an Australian government directive targeted at amoxicillin with clavulanic acid (AC) was associated with changes in prescription share, health care costs, and patient outcomes. We used an integrated database of computerized general practice medical records, which included data regarding 34,242 patients and 318,234 recorded patient visits. There were 15,303 antibiotic prescriptions provided to 9921 patients during a 4-year period, with AC prescribed for 1453 (14.6%) of these patients. A total of 5125 patient outcomes were identified. There was a shift away from best-practice antibiotic prescribing, and a significant association was identified between the rate and cost of process-of-care and patient outcomes and the decrease in AC-prescription share. This policy initiative created unintended changes in prescribing behavior, increased costs to the government, and a trend toward poorer patient outcomes. Detailed analyses are required before instigating initiatives aimed at changing clinicians' prescribing behavior.Justin Beilby, John Marley, Don Walker, Nicole Chamberlain, and Michelle Burke for the FIESTA Study Grou

Analytical method of predicting turbulence transition in pipe flow

The present analysis is based on the complete first law flow equation i.e. it includes the kinetic energy term that was neglected in earlier papers. It is shown that the results obtained with the proposed equations, derived from an Entropy Maximizing Principle, agree quite well with reliable data published in the scientific/technical literature

Effect of illicit direct to consumer advertising on use of etanercept, mometasone, and tegaserod in Canada: controlled longitudinal study

Objective To assess the impact of direct to consumer advertising of prescription drugs in the United States on Canadian prescribing rates for three heavily marketed drugs—etanercept, mometasone, and tegaserod

Copayments for prescription medicines on a public health insurance scheme in Ireland

Purpose: We assessed the impact of the introduction of a €0.50 prescription copayment, and its increase to €1.50, on adherence to essential and less-essential medicines in a publicly insured population in Ireland. Methods: We used a pre-post longitudinal repeated measures design. We included new users of essential medicines: blood pressure lowering, lipid lowering and oral diabetic agents, thyroid hormone, anti-depressants, and less-essential medicines: non-steroidal anti-inflammatory drugs (NSAIDs), Proton Pump Inhibitors/H2 antagonists (PPIs/H2), and anxiolytics/hypnotics. The outcome was change in adherence, measured using Proportion of Days Covered. We used segmented regression with generalised estimating equations to allow for repeated measurements. Results: Sample sizes ranged from 7145 (thyroid hormone users) to 136111 (NSAID users). The €0.50 copayment was associated with reductions in adherence ranging from -2.1%[95% CI, -2.8 to -1.5] (thyroid hormone) to -8.3%[95% CI, -8.7 to -7.9] (anti-depressants) for essential medicines and reductions in adherence of -2%[95% CI, -2.3 to -1.7] (anxiolytics/hypnotics) to -9.5%[95% CI, -9.8 to -9.1] (PPIs/H2) for less-essential medicines. The €1.50 copayment generally resulted in smaller reductions in adherence to essential medicines. Anti-depressant medications were the exception with a decrease of -10.0% [95% CI, -10.4 to -9.6] after the copayment increase. Larger decreases in adherence were seen for most less-essential medicines; the largest was for PPIs/H2 at -13.5% [95% CI, -13.9 to -13.2] after the €1.50 copayment. Conclusion: Both copayments had a greater impact on adherence to less-essential medicines than essential medicines. The major exception was for anti-depressant medicines. Further research is required to explore heterogeneity across different socio-economic strata and to elicit the impact on clinical outcomes

Effect of drug utilization reviews on the quality of in-hospital prescribing: a quasi-experimental study

BACKGROUND: Drug utilization review (DUR) programs are being conducted in Canadian hospitals with the aim of improving the appropriateness of prescriptions. However, there is little evidence of their effectiveness. The objective of this study was to assess the impact of both a retrospective and a concurrent DUR programs on the quality of in-hospital prescribing. METHODS: We conducted an interrupted time series quasi-experimental study. Using explicit criteria for quality of prescribing, the natural history of cisapride prescription was established retrospectively in three university-affiliated hospitals. A retrospective DUR was implemented in one of the hospitals, a concurrent DUR in another, whereas the third hospital served as a control. An archivist abstracted records of all patients who were prescribed cisapride during the observation period. The effect of DURs relative to the control hospital was determined by comparing estimated regression coefficients from the time series models and by testing the statistical significance using a 2-tailed Student's t test. RESULTS: The concurrent DUR program significantly improved the appropriateness of prescriptions for the indication for use whereas the retrospective DUR brought about no significant effect on the quality of prescribing. CONCLUSION: Results suggest a retrospective DUR approach may not be sufficient to improve the quality of prescribing. However, a concurrent DUR strategy, with direct feedback to prescribers seems effective and should be tested in other settings with other drugs

Stuck kids : a study examining the factors that contribute to hospitalized children getting placed on administrative days : a project based upon an investigation at a pediatric post-acute rehabilitation hospital

This study examined factors that contribute to medically complex children getting stuck in acute rehabilitation hospital level of care even though they were medically ready for discharge. Of special interest were caretaker and societal-related factors that may have a high potential for change and early intervention. Sample. Retrospective, non-comparative case series. Methods. The medical records of 20 children discharged between 2010 and 2012 from a specialty acute rehabilitation hospital in New England were surveyed using a protocol designed for the project. The children had been placed on administrative days (AD) prior to discharge. Univariate and bivariate analysis examined the impact of patient disease characteristics, parental characteristics, and societal factors on post-AD status length of stay. Findings. Although the final sample size (N=20) limited the reliability and types of statistical tests that could be undertaken, analysis suggested that disease factors interact with caretaker and societal factors to create the conditions that delay discharge. Findings from the study were used to inform the development of screening tools and targeted interventions for use by the Medical Social Work Service at the host hospital. And a recommendation was made to develop a prospective, comparative case series study of all admissions to further explore the factors identified in this pilot study