The impact of an intensive antimicrobial control program in a Taiwanese medical center.

OBJECTIVE: The study evaluates the short term impacts of an intensive control program for the appropriate us of antimicrobials, and to provide a novel strategy for antimicrobial control in inpatient wards in Taiwan. METHOD: In September 2002, a dual intensive antimicrobial control program was implemented within a 921-bed medical center in Taiwan. The study sample included all patients admitted to the medical center during the basal period (October-December 2001) and the intervention period (October-December 2002), where at least one type of parenteral antimicrobial was administered. The sample comprised of 5046 patients during the basal period and 5054 patients during the intervention period. MAIN OUTCOME MEASURE: Analysis of the impact of the intensive antimicrobial control program was undertaken by comparing clinical outcomes, parenteral antimicrobial consumption and bacterial susceptibilities, before and after the establishment of the intensive antimicrobial control program. RESULTS: No statistical differences were found between the basal and intervention periods with regard to either the demographic variables, such as age and gender, or the incidence of nosocomial infections. The clinical outcomes, including length of stay in the medical center, mortality and readmission rates, were also similar for both periods. As compared to the basal period, the consumption of parenteral antimicrobials--in defined daily doses (DDDs) per 100 patient days (PDs)--declined by 13.2% during the intervention period (71.2 vs. 61.8). There were significant increases in the susceptibilities of Pseudomonas aeruginosa to both amikacin and ciprofloxacin, and Serratia spp. to ciprofloxacin (P < 0.05), while all others remained stable. CONCLUSION: This study reports positive responses to intensive antimicrobial control measures among health professionals within a Taiwanese medical center. Following the implementation of the intensive control program, both prescriptions and consumption levels of parenteral antimicrobials were reduced without compromising the clinical outcomes of patients, while the susceptibility patterns of bacterial organisms mostly remained stable. Long-term control of parenteral antimicrobials under such a program may well produce significant benefits for inpatients through the overall rationalization of antimicrobial usage, leading to potential reductions in both the incidence of adverse effects and the burden of resistant organisms. A method of incorporating this intensive control program into a computerized prescription order system is currently under construction.

Utilization and drug cost outcomes of a step-therapy edit for generic antidepressants in an HMO in an integrated health system.

OBJECTIVE: Antidepressants do not differ significantly in their ability to treat depression. Excluding the tricyclic antidepressants (TCAs), these drugs also do not differ significantly in their incidence of adverse events. Therefore, the initial choice of antidepressant medication should be based, in part, on cost. The objective of this study was to evaluate the impact on utilization and costs of a generic steptherapy edit for antidepressant drugs excluding TCAs in a health maintenance organization (HMO) in an integrated health system (IHS). METHODS: The pharmacy department of the 440,000-member HMO in an IHS collaborated with the Behavioral Health Clinical Program to design an intervention that required generic antidepressants as first-line pharmacotherapy. Under the GenericStart! Program, a brand-name antidepressant was covered only after trial with a generic antidepressant, excluding TCAs. A step-therapy edit was added to the pharmacy claims processing system on January 1, 2005. All new starts, defined as members with no claims history of antidepressant treatment within the preceding 6 months, were required to use a generic antidepressant. The member copayment was waived for the first prescription. All generic antidepressants were in tier 1 of the drug formulary, with an average copayment of $5 to $10. All brand-name antidepressants were in either tier 2 (preferred brand), with an average copayment of $20 to $25 or 25% coinsurance, or tier 3 (nonformulary brand), with an average copayment of $40 to $45 or 50% coinsurance. Pharmacy claims data from a national pharmacy benefit manager (PBM) without interventions for antidepressants in 2004 or 2005 were used for the comparison group. RESULTS: The generic antidepressant dispensing rate increased by 20 points (32.5% to 52.5%) in the intervention group but only 7.4 points (24.9% to 32.3%) in the comparison group in 2005 compared with 2004. The principal measure of antidepressant drug cost per day of therapy in the intervention group decreased by 11.7% (from $2.40 to $2.12) in 2005 compared with 2004 versus a 2.7% decrease (from $2.60 to $2.53) in the comparison group (P <0.001). Days of antidepressant drug therapy per member per month (PMPM) dropped by 1.5% (from 1.74 to 1.71) in the intervention group versus a decrease of 5.0% (from 1.37 to 1.30) in the comparison group in 2005 compared with 2004. The combination of change in drug cost and utilization resulted in a 13.0% decrease in antidepressant drug cost, from $4.16 PMPM in 2004 to $3.62 in 2005, compared with a 7.6% decrease (from $3.57 to $3.30 PMPM) in the comparison group. The 9.0% difference in drug cost per day represents drug cost savings of approximately $0.36 PMPM or $1,880,562 in 2005 dollars for this HMO of approximately 440,000 members. CONCLUSION: A step-therapy edit requiring HMO members to use a generic antidepressant, excluding tricyclics, prior to use of a brand-name antidepressant resulted in drug cost savings of 9.0% for the entire class of antidepressants, equal to $1,880,562 ($0.36 PMPM) in 2005 dollars in the first year of the intervention. A small (-1.5%) decrease in use of antidepressants occurred in the intervention group, which was less than the 5.0% decrease in utilization of antidepressants in the comparison group.

Changes in prescribed drug doses after market introduction.

PURPOSE: The establishment of recommended dosing regimens has always been a difficult aspect of drug development. This paper examines the extent to which postmarketing prescribing deviates from initially recommended dosing regimens. We used the World Health Organization's (WHO) periodically updated compilation of the 'Defined Daily Dose' (DDD) to reflect prevailing patterns of prescribing in national markets. The aim of this study was to evaluate DDD changes over time (1982-2000) and to identify possible determinants of these changes. METHODS: Data on DDD changes were obtained from the WHO's Oslo Collaborating Centre. We performed a case-control analysis in which we compared drugs with (cases) and without (controls) postmarketing changes in DDD on possible determinants associated with DDD change. RESULTS: We found 115 instances of a change of DDD in the period 1982-2000 (45 (39.1%) increases and 70 (60.9%) decreases). Antibiotics showed the greatest number of changes in DDD: predominantly increases in the 1980s, while the 1990s were dominated by decreases in DDD of mostly cardiovascular drugs. CONCLUSION: Changes in DDD reflect the outcome of a melange of forces, including misconceptions of dose requirements during pre-market development of drug and postmarketing changes in pharmacotherapeutic knowledge, clinical concepts, economic forces, and, in the case of anti-infective agents, changing patterns of resistance/sensitivity of target microorganisms to the anti-infective agent(s) in question.

Cost of inappropriate use of ciprofloxacin in ambulatory care.

OBJECTIVE: To determine the incidence of inappropriate ciprofloxacin use and the resulting cost thereof in ambulatory care. DESIGN: Retrospective cost analysis. SETTING: Ambulatory care clinic of a Department of Veterans Affairs Medical Center. PATIENTS: One hundred thirty-seven ambulatory patients prescribed ciprofloxacin during March, April, and May 1992. Forty-six patient charts were available for review. MAIN OUTCOME MEASURE: Indications for ciprofloxacin use were determined from chart review. RESULTS: Chart review of 46 of the 137 patients prescribed ciprofloxacin during the three-month study period indicated that only 8 (17 percent) had infections that were appropriately treated with this antibiotic. If 550 patients had received ciprofloxacin that year (figure extrapolated from the three-month totals), the cost of prescribing would have been $29,260. This study indicates that $20,500 per year could be saved by prescribing equally efficacious oral antibiotics. CONCLUSIONS: Restricting ciprofloxacin use to its proven indications in the ambulatory setting may result in considerable cost savings to medical centers.