CorrectCare

The ‘Bottom Line’ Isn’t Always What It Seems
Pharmacists Learn to Look Beyond Price When Trying to Curb Costs

With budgets under increasing pressure, cost control is more important than ever. But in the quest to curb expenses, one apparent solution—switching to lower-priced drugs—may not always achieve the desired result, as Curtis Warren, RPh, can attest.

At the Florida Department of Corrections, where Warren is director of pharmacy services, the formulary committee was intrigued by the possibility of saving money by converting from omeprazole to lansoprazole when it found a lower acquisition cost for the latter drug. Both drugs are proton pump inhibitors, used to treat ulcers.

Before making the change, however, the committee conducted some research. A literature review suggested that the two drugs should be “totally interchangeable,” Warren says, but yielded no data about clinical outcomes after a conversion. The group decided to proceed with the conversion, but formed a subcommittee to study the clinical and fiscal effects, such as practitioner acceptance, utili-zation, efficacy and add-on therapies.

More specifically, study objectives were to determine:

• The general outcome of converted patients
• Utilization patterns before and after conversion
• The rate of add-on GI-type medications before and after conversion
• Dose and daily frequency of proton pump inhibitors in converted patients
• Estimated financial impact

The retrospective study targeted patients who were receiving omeprazole from January through June of 1999 and lansoprazole after July 1, 1999, when the conversion began. Ultimately, medical charts were analyzed for those 29 patients who had been on continuous omeprazole for 90 days prior to the conversion and who continued to receive treatment for at least 60 days postconversion. Chart data was entered into a customized database and analyzed for statistical significance.

UNINTENDED CONSEQUENCES
The results were bad news. “We found a significant rise in BID dosing, increased patient complaints and a substantial increase in utilization,” says Warren.

Nearly one-fourth of the patients reported various complaints, such as stomach pain, after switching to the new drug. “We didn’t expect that, based on what we found in the literature,” Warren notes. Other negative outcomes included clinical failure of the new treatment and the need for extra patient visits to the clinic.

Just as troubling, four patients ended up taking additional GI medications (metoclopramide, cisapride, ranitidine and antacid liquid) after switching to lansoprazole. This statistically significant outcome was attributed to the conversion since none of the patients had taken other GI meds previously.

As far as dosing, while a handful of patients had received omeprazole twice daily prior to the conversion, 12 more patients switched to that regimen after they started taking lansoprazole.

Given the higher utilization, the anticipated cost savings failed to materialize. In fact, analysis of systemwide purchasing data showed a $23,800 increase in cost in the six months following conversion. (See box for details.)

The exercise has been a valuable one for Warren and his formulary committee. In fact, it confirmed what he suspected: “Even a well-thought-out formulary conversion based on acquisition costs may not have the intended financial consequences. The practice of wholesale conversions of therapeutic classes based on acquisition costs should be abandoned.”

Warren also says that when adding new drugs to the formulary, it’s important to educate health care providers that the drug should be used only for patients new to the drug or those having problems with current medications.

— Editor’s note: Curtis Warren, RPh, and his colleague David Whaley, PharmD, displayed an educational poster on their findings at the 25th National Conference on Correctional Health Care in November 2001. To obtain a summary of their findings, e-mail Warren at warren.curtis@mail.dc.state.fl.us.

[This article first appeared in the Winter 2002 issue of CorrectCare.]