Pharmacy 483 Outcomes & Cost Management in Pharmacy Practice

1. Pharmacy 483 Outcomes & Cost Management in Pharmacy Practice Janet Kelly, Pharm.D., BC-ADM February 24, 2004

2. Health Care Cost Over Time

3. Factors Contributing to Increasing Medication Costs

4. Clinical Pharmacists Outcomes & Cost Management Formulary Management Providers (RN, MD, etc)

5. 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

6. How Can a Formulary Optimize Outcomes & Costs? • Standardization of Care • Appropriate Utilization • Improved Safety • Less Potential for Errors • Bulk Purchasing • Contract Pricing

7. Role of Clinical Pharmacists in Outcomes & Cost Management • Identification • Reality Check • Expertise • Implementation

8. Therapeutic Equivalency Therapeutic Equivalency UW Medicine Example: 5HT3 Antagonists Ondansetron (Zofran) Dolasetron (Anzemet) Granisetron (Kytril)

9. Equipotent Dosing IV Dosing Ondansetron 8mg Dolasetron 100mg Granisetron 1mg = = Oral Dosing Ondansetron 16mg Dolasetron 100mg Granisetron 2mg = =

10. Treatment Guidelines For Chemotherapy Induced Nausea/Vomiting

11. Cost Savings Associated with the 5HT3 Program at UW Medicine Net Savings = $534,000

12. New Drug Evaluation for Formulary • CLINICAL EFFICACY • Therapeutically superior to current formulary options • Effective for the treatment of condition which previously had no effective therapy • SAFETY • Improved safety and/or tolerability compared • to current therapeutic options while maintaining • therapeutic effectiveness • COST EFFECTIVENESS • Offers cost advantages to the institution for a given • outcome compared to current formulary options

13. How is Cost Effectiveness Defined? Therapeutic Outcomes Therapeutic Outcomes & Economic Evaluation = Cost Per Outcome

14. Steps in an Economic Evaluation • Determination of Total Cost • Determination of Reimbursement • Calculation of Potential Revenue

15. Darbepoetin: Formulary Evaluation • Clinical Evaluation (compared to Epoetin) • Similar efficacy with less frequent dosing ? Equivalent dosing ? Dose escalation • Similar safety ? Improved compliance

16. Economic Evaluation of Darbepoetin Determination of Costs: Drug Acquisition Rebates and Incentives for Other Amgen Products Convenience Less frequent administration Dollar Value ? Drug Administration Cost Clinic vs. Self Administered

17. Economic Evaluation of Darbepoetin Determination of Reimbursement: Ambulatory vs. Hospitalized Insurance Mix % Medicare, Medicaid, & Private Patient Responsibility Co-pays

18. Economic Evaluation of Pegfilgrastim Calculation of Profit Margin: - Total Cost Reimbursement = Profit Margin

19. UW Medicine Clinical Pathway for Darbepoetin for Anemia of CRI Hgb<11 g/dL Hgb<11 g/dL Check nutritional cofactors GOALS OF DARBEPOETIN THERAPY Resolution of Anemia : Hgb=12 g/dL Previously untreated pts 0.9 mcg/kg q 2 weeks* Previously untreated pts 0.9 mcg/kg q 2 weeks 2 week Follow Up Has Hgb Increased > 1g/dl over baseline? 2 week Follow Up Has Hgb Increased > 1g/dl over baseline? • Supplement with iron if: • Serum ferritin<100 mg/ml • Transferrin saturation<20% Yes No Continue Therapy NO DOSE INCREASE Continue Therapy NO DOSE INCREASE Decrease Dose by 25% Decrease Dose by 25% 6 week Follow Up Has Hgb> 1g/dl from baseline? 6 week Follow Up Has Hgb> 1g/dl from baseline? No Yes Recheck nutritional cofactors Recheck nutritional cofactors Increase dose to next vial size Maximum of 200 mcg q 2 weeks Increase dose to next vial size Maximum of 200 mcg q 2 weeks Continue Therapy If Hgb>12 decrease dose to next vial size Continue Therapy If Hgb>12 decrease dose to next vial size

20. UW Medicine – Clinical Pathway for Darbepoetin use in Chemotherapy Induced Anemia Hgb<11 g/dL Hgb<11 g/dL GOALS OF DARBEPOETIN THERAPY Resolution of Anemia : Hgb>12 g/dL Reduced need for transfusion Starting Dose: 200 mcg q2 wk or 300 mcg q 3wk • Supplement with iron if: • Serum ferritin<100 mg/ml • Transferrin saturation<20% 2 week Follow Up Has Hgb Increased > 1g/dl over baseline? 6 week Follow Up Has Hgb Increased > 1g/dl over baseline? Yes No Recheck nutritional cofactors Increase dose to 300 mcg q 2 wks Continue Therapy Yes 6 week Follow Up Has Hgb> 1g/dl from baseline? 12 week Follow Up Has Hgb> 1g/dl from baseline? No Recheck nutritional cofactors Recheck nutritional cofactors Consider discontinuing - Depending on Pt’s symptomatic response Monitor Hgb –hold if Hgb>13 Resume Tx when Hgb<12 200 mcg q3wks

21. Comparison of Cost Effectiveness Darbepoetin vs. Epoetin Therapeutic Outcome Equivalent & Economic Evaluation Beneficial = Cost Per Outcome Decreased

22. 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