joeparkspharmacymgmt
TRANSCRIPT
Pharmacy Utilization Management
Getting at Cost via Quality
The Issue
More patients on meds
More meds per patient
More cost per med
Limited evidence of benefit
Doctors
Pharma
Leadership“Drug therapies are replacing a lot of medicines as we used to know it.”
George W. BushOctober 17, 2000
Comments from St. Louis, Missouri Presidential Debate
Pharmacy Management Guiding Principles”
Manage through data, not intuition or anecdote.
Focus management interventions on good evidence, quality treatment guidelines and compliance with medication plans.
Don’t establish the primary goal as “cost savings”. Allow cost savings to be the natural result of evidence based care, quality and adherence to treatment guidelines;
Monitor for both planned and unplanned consequences.
Don’t punish the many, for the sins of the few. Target your Interventions to outliers who need it, not to compliers who don’t.
Our Duty = The Usual Accepted Standard of Practice
EVIDENCE
+
EXPERT CONSENSUS
+
ACTUAL PRACTICE
DISCUSSION AND DELIBERATION
Enforcing Good Practice
Documentation Standards
Restrictive Formulary
Algorithms
Documentation Standards
One or more target symptoms for each medication
Target symptoms that are measurableTarget symptoms scored at each visitExplicit time frame for re-evaluation.
Key Arguments
2nd generation antipsychotics are all unique in their mechanism of action
Psychiatrists can’t predict which patients will benefit most from which mechanism
Key Conclusions
Don’t withdraw access to a medication that’s clearly proven beneficial to that patient.
Do require trying less costly options first if there’s no proof of likely superiority in that particular patient (example: strong family history of benefit).
Difference Among SSRI’s
Safety – “remarkably similar” *Tolerability – “only modest differences”Efficacy – “not any difference”Relapse prevention ‘ “amazingly
consistent”* Except drug-drug interactions from “Clinical
Pharmacology of SSRI’s” Sheldon Preskorn 1996
SSRI Preference Algorithm
Depression OCD PMDD Bulimia PTSD
Panic Social Phobia
General Anxiety
Fluoxetine(Prozac/Sarafem)
X X X X X
Zoloft X X X X
Paxil X X X X X X
Celexa/Lexpro
X
Luvox X
FDA Indications for SSRI Antidepressants
SSRI Preference Algorithm
Automatic Exemptions (Approval) Any SSRI they are currently on Any SSRI there is a record of prior treatment
with Paxil if there is a prior diagnosis of PTSD, Social
Phobia, or General Anxiety on record Zoloft if there is a prior diagnosis of PTSD on
record Concomitant use MAOI, Thioridazine, or Opiates
Exemptions (Approvals) by Request
Physician reports and documents a diagnosis of PTSD for Zoloft usage
Physician reports and documents a diagnosis of PTSD, Panic Disorder, Social Phobia, or Generalized Anxiety for Paxil usage
Physician reports and documents prior usage of that SSRI with good efficacy
Physician reports patient has been on that SSRI at least 30 days prior
Physician reports and documents first degree relative had good treatment response to other SSRI
Redressing Bad Practice
Outlier Case Review
Guideline Congruence Review
Benchmarking
Best Practice Information
Expert Consensus Guideline Series www.psychguides.com
Texas Medication Algorithms
www.dshs.state.tx.us/mhprograms/TMAP.shtm
American Psychiatric Association
www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
Under Utilized Medications
First line Lithium
Second line – (doesn’t mean never)ClozapineTricyclic Antidepressants1st Generation Antipsychotics
Outlier Case Review
Patients on most individual medications
Patients on 3 or more in the same class
Patients on most prn’s
Guideline Congruence Reviews
Have patients on more than one antipsychotic had trial of monotherapy Clozapine?
Have patients on more than one antidepressant had trial of monotherapy TCAs?
Have patients on more than one new anticonvulsant had trials of Lithium and Valproate at adequate doses?
Have patients on more than one new antipsychotic had trial of monotherapy old antipsychotic?
Benchmarking
Choose indicators More than 5 psychotropic More than 1 antipsychotic More than 2 mood stabilizers More than 1 antidepressant
For each prescriber divide number of patients hitting one or more by all patients on medication class
Rank order by portion Discuss range in medical staff meeting
Practice Pitfalls
Rapid changesOver reliance on medicationUsing multiple new medications before
trying mono-therapy old medicationsUnder-dosingNot contacting community prescriber
Commonly Under Dosed Medications
Lithium
Valproic Acid (Depakote)
Tricyclic Antidepressants
Antipsychotic Non-Responders
Adequate Duration: 6-8 weeks4 Possibilities
Dose too lowDose too highWon’t help at any dose
Approach: Use Clozapine or Haldol and check serum level
Essential Input from Community Prescriber
For each individual medicationWhat’s the target symptom?How convinced are you that it’s helpful? Is it essential for successful treatment?
How reliable is the patient in taking meds?
What would they like addressed during hospitalization?