Targeting cardiovascular medication adherence interventions.

OBJECTIVES: To determine whether adherence interventions should be administered to all medication takers or targeted to nonadherers. DATA SOURCES AND STUDY SELECTION: Systematic search (Medline and Embase, 1966-2009) of randomized controlled trials of interventions to improve adherence to medications for preventing or treating cardiovascular disease or diabetes. DATA EXTRACTION: Articles were classified as (1) broad interventions (targeted all medication takers), (2) focused interventions (targeted nonadherers), or (3) dynamic interventions (administered to all medication takers; real-time adherence information targets nonadherers as intervention proceeds). Cohen's d effect sizes were calculated. DATA SYNTHESIS: We identified 7,190 articles; 59 met inclusion criteria. Broad interventions were less likely (18%) to show medium or large effects compared with focused (25%) or dynamic (32%) interventions. Of the 33 dynamic interventions, 6 used externally generated adherence data to target nonadherers. Those with externally generated data were less likely to have a medium or large effect (20% vs. 34.8% self-generated data). CONCLUSION: Adherence interventions targeting nonadherers are heterogeneous but may have advantages over broad interventions. Dynamic interventions show promise and require further study.

Prior authorization for biologic disease-modifying antirheumatic drugs: a description of US Medicaid programs.

OBJECTIVE: To evaluate state Medicaid prior authorization programs for biologic disease-modifying antirheumatic drugs (DMARDs). METHODS: We obtained biologic DMARD prior authorization policy information from state Medicaid programs. Using aggregate Medicaid drug spending data, we calculated the proportion of DMARD prescriptions and spending attributed to adalimumab and etanercept in 1999 and 2005 and compared the changes in these proportions in states with and without prior authorization policies. Infliximab and other infused DMARDs were not included because of substantial missing data. RESULTS: Thirty-two states required prior authorization for > or = 1 biologic DMARD, with wide variation in the specific agents covered and the criteria required for a drug to be authorized. There were 18 states with prior authorization requirements for adalimumab or etanercept. States that implemented prior authorization for these agents initially had lower use of the targeted medications, but use increased over time to a level similar to that in states that did not have prior authorization requirements. CONCLUSION: States vary widely in their implementation of prior authorization policies to limit use of biologic DMARDs. Although it appears that these policies may have a short-term effect on the use of targeted medications, this effect does not appear to be sustained. The clinical impact and appropriateness of such policies is not clear from our data and should be studied further.

Restrictions on antidepressant medications for children: a review of Medicaid policy.

OBJECTIVE: This study evaluated Medicaid's prior-authorization policies restricting the prescribing of antidepressant medications for children. METHODS: Medicaid program prior-authorization policies for antidepressant medications were obtained for all available states. All criteria needed for authorization were recorded, with a focus on policies that applied specifically to children. RESULTS: Data from 49 states and the District of Columbia revealed that 30 states (60%) required prior authorization for antidepressants, of which eight (27%) made specific provisions for children. These provisions varied across states. In most states fluoxetine could be prescribed for children with minimal restrictions, and two states had prior-authorization policies that strongly encouraged pediatric patients to use fluoxetine. State policies regarding other selective serotonin reuptake inhibitors varied widely. CONCLUSIONS: Although relatively few states included provisions for children in prior-authorization requirements for antidepressants, in states that did, the policies implemented varied widely. These findings raise important questions about the rational development of prescription drug reimbursement policy.