Title: Developing conditionspecific hospice formularies for CHF and depression and the evaluation of their
1Developing condition-specific hospice formularies
for CHF and depression and the evaluation of
their economic impact
- Nikhil G. Khandelwal
- Auburn University
- April 3, 2006
2Dissertation Committee
- Chair
- Dr. Kem Krueger
- Co-Chair
- Dr. Bruce Berger
- Committee members
- Dr. Marc Carpenter
- Beth Butz, M.S., Pharm.D.
- Prof. Bernie Olin
3Outline
- Overview
- Literature review
- Methods
- Results
- Discussion
- Question
4Literature review
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
5Literature 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.
6Literature 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
7Literature 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
8Study 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
9Study 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 -
10Study 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 -
11Research 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?
12Research 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?
13Research 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
14Research 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
15Methods
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
16Methods
- 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
-
17Methods
- 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(No Transcript)
19Methods
- 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
20STUDY 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
21Methods
- 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
22Results
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
23Results-Study Phase-I
Drugs Selected for Hospice Formulary- Depression
24Results-Study Phase-I
Drugs Selected for Hospice Formulary- CHF
25Results-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
26Results-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
27Results-Study Phase-II
- Comparisons of per patient day drug costs, across
- Pre and Post-formulary depression groups
p
28Results-Study Phase-II
- Comparisons of per patient day drug costs, across
- Pre and Post-formulary CHF groups
29Results-Study Phase-II
- Research Hypotheses-Depression
30Results-Study Phase-II
31Results-Study Phase-II
- Pre and Post-Depression Formulary Cost Analysis
For Depression-Specific Drugs
Post-Formulary costs Contract price
Formulary effect
32Results-Study Phase-II
- Pre and Post-Depression Formulary Cost Analysis
Using Pre-formulary Drug Price Information
33Results-Study Phase-II
- Cost Savings Achieved from Depression Formulary
34Results-Study Phase-II
- Pre and Post-CHF Formulary Cost Analysis For
CHF-Specific Drugs
Post-Formulary costs Contract price
Formulary effect
35Results-Study Phase-II
- Pre and Post-CHF Formulary Cost Analysis Using
Pre-formulary Drug Price Information
36Results-Study Phase-II
- Cost Savings Achieved from CHF Formulary
37Projected Cost Savings Due to Formulary
Implementation
38Discussion
1. Literature review 2. Methods 3.
Results 4. Discussion 5. Question
39Discussion
- 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
40Discussion
- 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
41Discussion
- 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 -
42Discussion
- 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.
43Discussion
- 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
44Discussion
- 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
45References
- 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.
46Thank You