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

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


1
Developing condition-specific hospice formularies
for CHF and depression and the evaluation of
their economic impact
  • Nikhil G. Khandelwal
  • Auburn University
  • April 3, 2006

2
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

3
Outline
  • Overview
  • Literature review
  • Methods
  • Results
  • Discussion
  • Question

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

6
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

7
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

8
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

9
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

10
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

11
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?

12
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?

13
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

14
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

15
Methods
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
16
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

17
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.

18
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19
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

20
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
21
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

22
Results
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
23
Results-Study Phase-I
Drugs Selected for Hospice Formulary- Depression
24
Results-Study Phase-I
Drugs Selected for Hospice Formulary- CHF
25
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
26
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
27
Results-Study Phase-II
  • Comparisons of per patient day drug costs, across
  • Pre and Post-formulary depression groups

p
28
Results-Study Phase-II
  • Comparisons of per patient day drug costs, across
  • Pre and Post-formulary CHF groups

29
Results-Study Phase-II
  • Research Hypotheses-Depression

30
Results-Study Phase-II
  • Research Hypotheses-CHF

31
Results-Study Phase-II
  • Pre and Post-Depression Formulary Cost Analysis
    For Depression-Specific Drugs

Post-Formulary costs Contract price
Formulary effect
32
Results-Study Phase-II
  • Pre and Post-Depression Formulary Cost Analysis
    Using Pre-formulary Drug Price Information

33
Results-Study Phase-II
  • Cost Savings Achieved from Depression Formulary

34
Results-Study Phase-II
  • Pre and Post-CHF Formulary Cost Analysis For
    CHF-Specific Drugs

Post-Formulary costs Contract price
Formulary effect
35
Results-Study Phase-II
  • Pre and Post-CHF Formulary Cost Analysis Using
    Pre-formulary Drug Price Information

36
Results-Study Phase-II
  • Cost Savings Achieved from CHF Formulary

37
Projected Cost Savings Due to Formulary
Implementation
38
Discussion
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
39
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

40
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

41
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

42
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.

43
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

44
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

45
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.

46
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