Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance.

BACKGROUND: Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures. METHODS: In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations. RESULTS: The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%. CONCLUSIONS: This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.).

Impact of the implementation of a nurse-managed outpatient parenteral antibiotic therapy (OPAT) system in Baltimore: a case study demonstrating cost savings and reduction in re-admission rates.

Objectives: Evidence supports the safety and effectiveness of outpatient parenteral antibiotic therapy (OPAT). A registered nurse (RN)-managed multidisciplinary team OPAT model was implemented at our hospital. We evaluated the impact of the new OPAT model on readmissions during OPAT and other core OPAT processes. Methods: All potential OPAT cases from 1 November 2013 to 31 June 2017 discharged from the Johns Hopkins Bayview Medical Center were followed up in a retrospective cohort study. Relevant clinical and patient characteristics were collected for the first OPAT course per patient. The primary outcome was all-cause readmission to any facility part of the Johns Hopkins Health System within 30 days of OPAT discharge. Proportions of OPAT patients readmitted before and after the implementation of the new OPAT model were compared. A log-binomial regression was used to compare the risk of readmission, adjusted for age, sex, race/ethnicity, site of OPAT care, opioid dependence and OPAT treatment duration. Results: Five hundred and seventeen OPAT patients were included in the analysis; 51.1% were discharged after the implementation of the new OPAT model. Readmission rates decreased from 20.2% to 13.3% following the RN-managed OPAT programme (P = 0.04). The results of the adjusted model indicated that nurse management was associated with a 39% reduction in the risk of readmission (adjusted relative risk 0.61; 95% CI 0.41-0.91; P = 0.01). Our financial evaluation estimated that the reduction in readmissions achieved by the RN-managed model saved the hospital $649 416 over 15 months. Conclusions: The RN-managed OPAT programme was associated with a significant reduction in readmissions.

Impacts on health outcomes and on resource utilisation of home-based parenteral chemotherapy administration: a systematic review protocol.

INTRODUCTION: Despite the demonstrated feasibility and policies to enable more to receive chemotherapy at home, in a few countries, parenteral chemotherapy administration at home remains currently marginal. Of note, findings of different studies on health outcomes and resources utilisation vary, leading to conflicting results. This protocol outlines a systematic review that seeks to synthesise and critically appraise the current state of evidence on the comparison between home setting and hospital setting for parenteral chemotherapy administration within the same high standards of clinical care. METHODS AND ANALYSIS: This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols approach. Electronic searches will be conducted on bibliographic databases selected from the earliest available data through 15 November 2017 published in French and English languages. Additional potential papers in the selected studies and grey literature will be also included in the review. The review will include all types of studies exploring patients receiving anticancer drugs for injection at home compared with patients receiving the drugs in a hospital setting, and will assess at least one of the following criteria: patients' health outcomes, patients' or caregivers' satisfaction, resource utilisation with cost savings, and incentives and/or barriers of each admission setting according to patients' and relatives' points of view. Two reviewers will independently screen studies and extract relevant data from the included studies. Methodological quality of studies will be assessed using the 'Quality Assessment Tool for Quantitative Studies' developed by the Effective Public Health Practice Project tool, in addition to the Consolidated Health Economic Evaluation Reporting Standards statement for economic studies. ETHICS AND DISSEMINATION: As the review is focused on the analysis of secondary data, it does not require ethics approval. The results of the study will be disseminated through articles in peer-reviewed journals and trade publications, as well as presentations at relevant conferences. PROSPERO REGISTRATION NUMBER: CRD42017068164.

Antimicrobial utilization in an Iraqi province: a comprehensive evaluation of antibiotic source and cost.

PURPOSE: The aims were to calculate total systemic antibiotic consumption and cost in both public and private sectors in all care settings in Al-Najaf province, Iraq, during 2012, recognize the percentage of each pharmacological class for the dispensed antibiotics and identify oral and parenteral antibiotic percentages dispensed and the portions manufactured nationally and imported. METHODS: Cross-sectional study was conducted in Al-Najaf to calculate the total cost and quantities of antibiotics consumed during 2012 using World Health Organization Guidelines for Defined Daily Dose (DDD). KEY FINDINGS: The results showed more than 21 million DDDs were dispensed in Al-Najaf in one year, and more than half (54.2%) were dispensed by governmental healthcare institutions. A thousand inhabitants in the province consumed 45.26 DDDs per day. Extended-spectrum (34.49%) and combined penicillins (26.08%) were the most frequently consumed while meropenem was the least frequently consumed (0.02%). Ninety-five per cent of the consumed antibiotics were oral dosage forms, and five per cent were parenteral dosage forms. The total cost of antibiotic consumed was more than nine million U.S dollars. CONCLUSIONS: The antibiotic consumption ratio in this province was comparable to neighbouring countries, but far higher compared to European countries. Penicillins, cephalosporins and quinolones were the most popular antibiotics. Around half of the antibiotics consumed were made by national pharmaceutical companies that mainly produce oral antibiotics. The public sector consumed a higher portion, but spent a lower amount compared to private sectors. This is the first time report of antibiotic consumption in Iraq. More studies evaluating antibiotic consumption can improve utilization.

International outpatient parenteral antimicrobial therapy.

On an international basis, outpatient parenteral antimicrobial therapy (OPAT) varies greatly. There are cultural as well as economic issues which make it different in every country. In general, the duration of hospital stay varies with the outpatient resources available and the economic base for them. In some countries, there may not be money available for any intravenous antibiotics, even in the hospital. In addition, there are great differences in outpatient intravenous therapy, with infusion clinics proliferating in China, yet these are scarce in the UK. There is also considerable variation in the use of intramuscular compared with intravenous therapies. In Italy, intramuscular ceftriaxone is used more often than intravenous therapy. While ceftriaxone use is high in the US, its use is surpassed on a per capita basis by Italy, and it is most interesting that the rate of antimicrobial resistance is lower in Italy than in most other European countries. Whether this relates to outpatient use, parenteral use or other unknown factors is unclear. Obviously, further studies are necessary.

Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside.

OBJECTIVE: An out-patient and home parenteral antibiotic therapy programme for the treatment of suitable infections was developed over a four year period. This paper describes the impact of one year's experience of its implementation on various measures of outcome. DESIGN: Each patient treatment has a full integrated care pathway (ICP) and patient satisfaction questionnaire completed. The ICP documents the clinical progress of the patient and incorporates various measures of quality of care on the 101 number of patients treated from April 1998 to March 1999 are presented here. SETTING: Dundee Teaching Hospitals NHS Trust (now Tayside University Hospitals NHS Trust). SUBJECTS: Patients with a range of infections requiring intravenous antibiotics. MAIN MEASURES: Number of patients treated with various infections, clinical and microbiological outcome, drug and vascular access complication rates, impact on drug costs and in-patient bed days, and measurement of patient satisfaction/quality of life. RESULTS: Patients were treated over a 12 month period. 51.5 per cent had skin & soft tissue infections and 22.8 per cent bone & joint sepsis. 57 per cent of patients received out-patient and 34 per cent self or carer administered home therapy. Ninety-four per cent of patients were cured or improved following treatment. Only 7.5 per cent of patients required an unscheduled admission to hospital. Twelve per cent of patients had some type of vascular device related adverse event (partly due to a faulty batch of lines) and six per cent of patients had a drug related reaction. The additional daily cost of drugs was minimal (< 12 Pounds/day) and more than 1,461 bed days have been saved across the Directorates. The patient satisfaction level was high.

Use, misuse, and cost of parenteral cephalosporins at a county hospital.

We reviewed total usage of parenteral cephalosporins at a county hospital during 1978 with regard to appropriateness, pattern of use, and cost. In addition, we determined the impact of replacing cephalothin with cephapirin in the hospital formulary. During the 12-month study 366 patients received 409 courses of parenteral cephalosporins: 167 received cefazolin, 160 received cephapirin, and 35 received a combination of cefazolin and cephapirin. The surgical service prescribed 87% of the cephapirin and 92% of the cefazolin. Parenteral cephalosporins were used 62% of the time for prophylaxis and 38% of the time for therapy. Usage was judged inappropriate in 47% of all courses based on our criteria; 25% of the therapeutic courses were judged inappropriate, compared to 60% of the prophylactic courses. Pharmacy costs of cefazolin used as prophylaxis were more than twice the cost for cephapirin. Cost of a mean therapeutic course for cefazolin was 43% higher than for cephapirin. Antibiotic audits and continued education combined with judicial substitution of therapeutic equivalents should limit the inappropriate use and expense of parenteral cephalosporins for large as well as small hospitals.