Physician perceptions about restricted access to medications and resultant outcomes: Implications fo

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Physician perceptions about restricted access to
medications and resultant outcomes
Implications for Manage Care Formularies

• Presenter Jason Lambrecht, Pharm.D.
• Fellow, Practice Improvement and Outcomes
  Research
• Investigators Kimberly A. Galt, Pharm.D.,
  F.A.S.H.P., Paul Turner, M.S., and Michelle
  Sodorff, Pharm.D., Creighton University
• Sarah Smith-Shull, Pharm.D. and Michael
  Sitorius, M.D., University of Nebraska Medical
  Center, Omaha, Nebraska

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Goals of the Formulary/System

• Select optimal drugs
• Assure quality - control cost
• Promote cost-effective care
• Historic - direct patient
• care environment

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Competing Formularies ... Conflicting Values

• Direct Patient Care Organization
• quality care at acceptable cost
• cost-effective alternatives
• individual patient need
• Benefits Manager or Payor
• - keep contract holders
• - acceptable cost
• - population based

• Prescribers do not differentiate these basic
  differences in formularies

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Restrictive/Closed Formularies

• HMO Closed Formularies

CibaGeneva Pharmacy Benefit Report - 1996 Trends
and Forecasts.
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Measures of Formulary Effectiveness

• Traditional
• The Drug Budget
• Per-Member-Per-Month Drug Costs
• Adverse drug reaction avoidance
• Effectiveness Redefined to Outcomes
• (Clinical) Clinical outcome of patient
• (Humanistic) Quality of life - satisfaction
• (Economic) Acceptable cost to.
• Intermittent measurements condition specific

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Purpose

• This study determined primary care physician
  perceptions of
• the frequency that their patients encounter
  restricted access to medications from payor
  formularies,
• the resultant outcomes, and
• those conditions for which restricted payor
  formularies are clinically acceptable to
  physicians.

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Description of Research

• Simple conditions Drug therapy management is
  Simple when the condition is
• self-limited
• known/predictable outcomes from treatment
• known treatment(s) few needed

• Complex conditions
• Drug therapy management is complex when the
  condition is
• chronic
• individual likelihood of successful treatment is
  not known
• many treatment options all needed in order to
  properly select

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Methods

• Study Design cross-sectional design in which
  fax-returned surveys were mailed using a modified
  Dillman technique.
• Methods 89 primary care physicians (60 family
  medicine, 40 internal medicine) were surveyed
  about 24 common conditions encountered in the
  ambulatory setting.

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Methods

• 24 conditions selected through ICD-9-CM billing
  codes for highest frequency
• Mini-delphi technique - 5 experienced physicians
  piloted survey, refined instrument.
• clear agreement between physicians
• chronic illnesses perceived as complex to manage

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Survey Items

• Self reported perceptions of common diseases
  managed through medication use
• drug treatment is simple or complex
• confident when treatment selected that patient
  will respond successfully (predictability of
  outcomes from treatment)
• breadth of treatment choices needed to achieve
  the desired outcomes (1-2 treatments simple)

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Survey Items

• Have your patients ever been denied access to a
  drug therapy? - if yes, indicate impact
• 1 no impact to my knowledge
• 2 delay in treatment
• 3 poor clinical outcome
• 4 patient expressed dissatisfaction
• 5 increased use of health care services

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Results

• Response rate was 71 (n62/89).
• Respondents spent an average of 71.2 of their
  time in ambulatory primary care clinic practice.
• No differences were observed, controlling for
  training background, gender, age or years of
  experience.

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Results Perceptions

• Between 33.9 - 70.9 perceived medication access
  problems for their patients depending on the
  condition.
• Between 14.3 and 80.6 perceived adverse outcomes
  when restricted access occurred, depending on the
  condition.
• Agreement was reached for 15 of 24 (62)
  conditions
• 8 (33) simple and 7 (29) complex
• 9 (38) no agreement.

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Simple vs. Complex

• Simple
• Gastroenteritis
• URI
• UTI
• Sinusitis
• Pharyngitis
• Rhinitis
• Hyperlipidemia
• Pneumonia

• Complex
• Angina
• COPD
• Arthritis
• CHF
• Asthma
• Migraine
• Weight loss

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Results

• Perceptions were that restricted formularies are
  consistent with physicians clinical concepts of
  management for about one-third of the conditions
  studied, i.e., simple conditions.
• 25 of the conditions were considered complex-
  requiring a broad range of therapies - a conflict
  in clinical management concepts for respondents.
• A more discerning model is needed for managed
  care formulary decision making.