Developing conditionspecific hospice formularies for CHF and depression and the evaluation of their

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Developing condition-specific hospice formularies
for CHF and depression and the evaluation of
their economic impact

• Nikhil G. Khandelwal
• Auburn University
• April 3, 2006

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Dissertation Committee

• Chair
• Dr. Kem Krueger
• Co-Chair
• Dr. Bruce Berger
• Committee members
• Dr. Marc Carpenter
• Beth Butz, M.S., Pharm.D.
• Prof. Bernie Olin

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Outline

• Overview
• Literature review
• Methods
• Results
• Discussion
• Question

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Literature review
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
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Literature review

• Hospice -comprehensive, coordinated, and
  compassionate care provided to people with
  limited life expectancy1
• The goal is to provide relief from suffering
  including pain and other symptoms
• Special emphasis on maximizing the quality of
  life for terminally-ill patients.

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Literature review

• Medicare is the primary funding source and
  reimburses hospices on a per diem (fixed daily)
  rate2
• Pays for medical services, spiritual services,
  social services, drugs, medical appliances, home
  health aide and homemaker services, and any other
  item or service as needed to manage the patients
  terminal illness3
• Due to restricted Medicare funding, there is
  limited ability for hospices to deliver optimum
  end-of-life care2

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Literature review

• Total pharmacy costs in hospices are increasing
  and represent a larger portion of the total
  direct costs4
• Experts in the field recommend that hospices
  develop drug formulary to curb the rising drug
  costs3
• There are no data or information available
  indicating the use of drug formularies in
  hospices3

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Study Purpose

• The study aimed at developing condition-specific
  hospice formulary, using the Multi-Attribute
  Utility Theory (MAUT) method6
• Additionally, the study evaluated the economic
  impact of drug agents selected in the
  condition-specific hospice formulary
• For this study, hospice formularies for CHF and
  depression conditions were developed

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Study Objectives

• To develop a rational depression-specific hospice
  formulary based on Multi-Attribute Utility Theory
  (MAUT) method
• To compare
• - depression-total drug cost, per patient
  enrollment day
• - depression-specific drug cost, per patient
  enrollment day
• - depression-other drug cost, per patient
  enrollment day
• six months before and six months after the
  washout period following the implementation of
  the depression formulary

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Study Objectivescontinued

• To develop a rational CHF-specific hospice
  formulary based on Multi-Attribute Utility Theory
  (MAUT) method
• To compare
• - CHF-total drug cost, per patient enrollment
  day
• - CHF-specific drug cost, per patient
  enrollment day
• - CHF-other drug cost, per patient enrollment
  day
• six months before and six months after the
  washout period following the implementation of
  the CHF formulary

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Research Questions

• Research Question 1
• Is there a difference in the depression-total
  drug cost, per patient enrollment day, before and
  after implementation of the depression formulary?
• Research Question 2
• Is there a difference in the depression-other
  drug cost, per patient enrollment day, before and
  after implementation of the depression formulary?
• Research Question 3
• Is there a difference in the depression-specific
  drug cost, per patient enrollment day, before
  and after implementation of the depression
  formulary?

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Research Questionscontinued

• Research Question 4
• Is there a difference in the CHF-total drug
  cost, per patient enrollment day, before and
  after implementation of the CHF formulary?
• Research Question 5
• Is there a difference in the CHF-other drug
  cost, per patient enrollment day, before and
  after implementation of the CHF formulary?
• Research Question 6
• Is there a difference in the CHF-specific drug
  cost, per patient enrollment day, before and
  after implementation of the CHF formulary?

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Research Hypotheses

• Research Hypothesis 1
• H1 There is a difference in the
  depression-total drug cost, per patient
  enrollment day, before and after implementation
  of the depression formulary
• Research Hypothesis 2
• H2 There is a difference in the
  depression-other drug cost, per patient
  enrollment day, before and after implementation
  of the depression formulary
• Research Hypothesis 3
• H3 There is a difference in the
  depression-specific drug cost, per patient
  enrollment day, before and after implementation
  of the depression formulary

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Research Hypothesescontinued

• Research Hypothesis 4
• H4 There is a difference in the
  CHF-specific drug cost, per patient enrollment
  day, before and after implementation of the CHF
  formulary
• Research Hypothesis 5
• H5 There is a difference in the CHF-other
  drug cost, per patient enrollment day, before and
  after implementation of the CHF formulary
• Research Hypothesis 6
• H6 There is a difference in the
  CHF-specific drug cost, per patient enrollment
  day, before and after implementation of the CHF
  formulary

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Methods
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
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Methods

• Study setting
• Hospice of East Alabama Medical Center (EAMC),
  located in
• Auburn, Alabama
• Study Phases
• Study Phase-I Develop condition-specific hospice
  drug formularies
• Study Phase-II Evaluate economic impact of
  condition-specific hospice drug formularies
• Study design
• Separate sample pretestposttest design

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Methods

• Steps Followed in Study Phase-I
• Step1 Identify different therapeutic drug
  classes for managing CHF and depression
  conditions.
• Step2 Conducted literature review on drug agents
  represented in different therapeutic classes.
• Step3 Identify drug selection criteria (drug
  attributes and factors).
• Step4 Compile literature-based (factor) values
  for all study drugs .
• Step5 Conduct first focus group meeting for
  evaluating and determining rankings and
  weightings of different drug selection criteria.
• Step6 Compute total utility score for individual
  study drug and rank the drugs in descending
  order.
• Step7 Conduct second focus group meeting for
  making final drug selection for the two
  condition-specific hospice formularies.

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Methods

• Study Phase-II
• Separate samples pre-test and post-test
  (depression and CHF) patients were identified and
  selected six months before and six months after
  the one-month washout period, following
  implementation of the formulary
• Total drug costs, condition-specific drug costs,
  and the other drug costs related to the study
  conditions were computed in terms of per patient
  enrollment day, which were then statistically
  compared

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STUDY PHASE-II SCHEMATIC REPRESENTATION
Six-months after the washout period, following
implementation of the formulary
Terminally-ill patients with a diagnosis of
CHF/depression who had at least 30 days of
documented care between September 1, 2005 to
February 28, 2006
Postformulary- retrospective data analysis
Preformulary- retrospective data analysis
Terminally-ill patients with a diagnosis of
CHF/depression who had at least 30 days of
documented care between January 1, 2005 to
June30, 2005

• Pre-formulary
• Total drug costs for treating the
• condition, per patient day
• Condition-specific-drug costs, per
• patient day
• Other drug costs related to
• condition, per patient day

• Post-formulary
• Total drug costs for treating the
• condition, per patient day
• Condition-specific-drug costs, per
• patient day
• - Other drug costs related to
• condition, per patient day

Comparison between pre-formulary and
post-formulary drug costs
Conducted statistical analyses to test study
hypotheses
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Methods

• Data analyses
• Compare patient characteristics
• Descriptive statistics, two-sample independent
  t-tests (for continuous variables) and chi-square
  analysis (for categorical variables) were
  employed to examine comparability of
  pre-formulary and post-formulary samples
• Testing research hypotheses
• Parametric and non-parametric statistical tests
  (such as two-sample independent t-tests and
  Wilcoxon 2-sample tests) were conducted to tests
  different research hypotheses

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Results
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
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Results-Study Phase-I
Drugs Selected for Hospice Formulary- Depression
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Results-Study Phase-I
Drugs Selected for Hospice Formulary- CHF
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Results-Study Phase-II

• Patient characteristics-
• Pre and Post-formulary depression groups

T-tests were used to compare continuous variables
across pre and post-formulary groups Chi-square
tests were used to compare the gender or
ethnicity differences across groups
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Results-Study Phase-II

• Patient characteristics-
• Pre and Post-formulary CHF groups

T-tests were used to compare continuous variables
across pre and post-formulary groups Chi-square
tests were used to compare the gender or
ethnicity differences across groups
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Results-Study Phase-II

• Comparisons of per patient day drug costs, across
  
• Pre and Post-formulary depression groups

p
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Results-Study Phase-II

• Comparisons of per patient day drug costs, across
  
• Pre and Post-formulary CHF groups

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Results-Study Phase-II

• Research Hypotheses-Depression

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Results-Study Phase-II

• Research Hypotheses-CHF

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Results-Study Phase-II

• Pre and Post-Depression Formulary Cost Analysis
  For Depression-Specific Drugs

Post-Formulary costs Contract price
Formulary effect
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Results-Study Phase-II

• Pre and Post-Depression Formulary Cost Analysis
  Using Pre-formulary Drug Price Information

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Results-Study Phase-II

• Cost Savings Achieved from Depression Formulary

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Results-Study Phase-II

• Pre and Post-CHF Formulary Cost Analysis For
  CHF-Specific Drugs

Post-Formulary costs Contract price
Formulary effect
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Results-Study Phase-II

• Pre and Post-CHF Formulary Cost Analysis Using
  Pre-formulary Drug Price Information

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Results-Study Phase-II

• Cost Savings Achieved from CHF Formulary

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Projected Cost Savings Due to Formulary
Implementation
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Discussion
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
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Discussion

• Study Phase-I
• MAUT method assisted in decreasing personal bias
  or group bias that could otherwise occur, while
  making drug selection
• Consensus regarding the drug agents selected for
  the formulary was achieved in an efficient manner
  
• In the post-formulary period, non-formulary
  agents were not used by the hospice clinicians

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Discussion

• Study Phase-II
• Only depression-specific drug costs per patient
  day was found to be significantly different in
  the pre and post-formulary depression groups
• Although, there was a reduction in the
  CHF-specific drug costs per patient day in the
  post-formulary period as compared to the pre
  period, the difference was not found to be
  statistically significant
• Formulary, as an effective cost-containment tool
  is still questionable

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Discussion

• Conclusion
• MAUT method is an effective decision-making tool
  that was used for developing formulary in a
  hospice setting, as
• It assisted the drug selection committee in
  understanding the various attributes and factors
• The clinicians at the center successfully adhered
  to using the formulary agents for their patients
  that were selected in this study and
• For individual condition-specific formulary, drug
  cost savings were achieved

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Discussion

• Limitations
• Study conducted at one hospice center, findings
  about the drug selection cannot be generalized
• Only those drug factors that were commonly
  assessed in the literature were included
• Two separate samples pre-test post-test design
  was employed as opposed to an experimental design
• Sample size issues
• Overall healthcare costs were not measured, which
  would have given a better understanding or a
  holistic view of the economic impact of the
  formularies.

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Discussion

• Implications
• MAUT methodology can be applied for developing
  formularies for other clinical conditions and at
  different hospice settings
• For formulary agents, hospices may negotiate
  better contract prices from the buying groups

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Discussion

• Future Research
• To increase the reliability of the formulary
  development methods used in this study, similar
  research could be replicated at other hospices
• Similar methodology can be utilized for
  developing formularies for clinical conditions,
  not covered in the scope of this study
• Economic impact of the drug formularies should be
  further studied using larger sample size for pre
  and post-formulary groups, and using information
  on the overall healthcare costs including the
  medical and non-medical costs
• MAUT methodology can be utilized for developing
  hospice formularies and further clinical and
  humanistic outcomes, related to the drug agents
  selected for the formulary should be analyzed

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References

• NHPCO-National Hospice and Palliative Care
  Organization. (n.d.) What is hospice and
  palliative care? Retrieved October 30, 2004 from
  http//www.nhpco.org/i4a/pages/index.cfm?pageid32
  81
• MedPAC. (2004). Hospice care in Medicare Recent
  Trends and a review of issues. Report to the
  Congress New approaches in Medicare. Retrieved
  October 30, 2004 from www.medpac.gov/publications
  5Ccongressional_reports5CJune04_ch6.pdf
• CMS-Center for Medicare and Medicaid Services.
  Hospice services. Retrieved October 20, 2004 from
  http//www.cms.hhs.gov/medicaid/services/hospice.a
  sp
• Families USA. (2004). Sticker Shock Rising
  Prescription drug prices for seniors. Retrieved
  August 2, 2004 from http//www.familiesusa.org/sit
  e/DocServer/Sticker_Shock.pdf?docID3541
• ASHP-Principles of a Sound Drug Formulary System.
  Retrieved August 13, 2004 from
  http//www.ashp.org/bestpractices/formulary-mgmt/F
  orm_End_Principles.pdf
• Schumacher, G.E. (1991). Multiattribute
  evaluation in formulary decision-making as
  applied to calcium-channel blockers. American
  Journal of Hospital Pharmacy, 48, 301308.
• ACC/AHAb (2003) Guidelines for Evaluation and
  Management. Chronic heart failure in the adult.
  Journal of American College of Cardiology, 38,
  2101-2113.

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Thank You