Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was...
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Transcript of Antipsychotic Utilization: Oregon State Medicaid Ann M. Hamer, PharmD BCPP This presentation was...
Antipsychotic Utilization: Oregon State Medicaid
Ann M. Hamer, PharmD BCPP
This presentation was made possible by a grant from the State Attorney General Consumer and Prescriber Education Program which is funded by the multi-state settlement
of consumer fraud claims regarding the marketing of the prescription drug Neurontin
Background
In 2004, Warner-Lambert (now a division of Pfizer, Inc.) paid $430 million to settle claims that it was using continuing education grants to promote off-label uses of Neurontin.
Background
The 50 state attorneys general who accepted the settlement of the Neurontin case have used $21 million to establish the Consumer and Prescriber Grant Program, www.ohsu.edu/cpgp/, designed to provide healthcare professionals and consumers information related to prescription drugs and their marketing.
Objectives
Develop critical skills to promote an evidence-based approach to the medical literature;
Create awareness of the persuasive marketing practices of the pharmaceutical industry;
Assess the impact that pharmaceutical costs can have on other healthcare priorities;
Balance the ethical responsibility to the patient vs. the ethical needs of society in prescribing practices; and
Develop skepticism about off-label indications for a drug without compelling evidence-based research that supports such use.
Methods
Academic Detailing Focused on the utilization of behavioral health
medications Didactic Lectures
Focused on the evaluation of medical literature and pharmaceutical marketing
Web-Based Tutorials Focused on the evaluation of medical
literature and pharmaceutical marketing
Topic Selection
Antipsychotics After specialty pharmaceuticals, antipsychotics
are the most expensive drug class for the Oregon Health Plan
Costing approximately $3.2 million each quarter Drug class where small changes can have a
big impact on overall cost Provides a good example of some off-label
use
Antipsychotic Utilization Profile
Antipsychotic Prescribing Rate—State
0
500
1000
1500
2000
2500
3000
3500
4000
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
Antipsychotic Prescribing Rate—State
0
500
1000
1500
2000
2500
3000
3500
4000
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
2%
28%
Antipsychotic Prescribing Rate—Lifeworks NW
0
10
20
30
40
50
60
70
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
2%
41%
Antipsychotic Prescribing Rate—Comparison
0%
5%
10%
15%
20%
25%
30%
35%
40%
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
Lifeworks State
Antipsychotic Selection
Cost is a factor in treatment selection when all else is considered equal.
Abilify Risperdal
Antipsychotic Selection
Cost is a factor in treatment selection when all else is considered equal.
Abilify
Generic Risperidone
Antipsychotic Utilization Profile
Seroquel Dosing*—State
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
Seroquel Dosing*—State
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
14%
86%
Seroquel Dosing*—Lifeworks
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
*Reflects use of dose for ≥90 days
31%
69%
Seroquel
69% of patients on therapy for 90 or more days were on low dose (<300mg/day). Total n=24
31% of patients on therapy for 90 or more days were on therapeutic dose (300-800mg/day) Total n=6
No patients were on duplicate antipsychotic therapy with Seroquel for 90 or more days.
Roughly 50% of patients started on Seroquel maintain treatment for 90 or more days.
Low Dose Seroquel
The use of Seroquel as a sedative has not been studied and efficacy and safety are questionable.
Adverse effects = anticholinergic side effects, hypotension, hyperprolactinemia, metabolic abnormalities, agitation and akathisia.
Low Dose Seroquel
Cases of Seroquel misuse and abuse have been reported in the medical literature. Street name = “quell” and “Susie-Q”
Antipsychotic Utilization Profile
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Risperdal & perphenazine, % of all AP use,
excluding clozapine and select 1st generation AP
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Risperdal & perphenazine, % of all AP use,
excluding clozapine and select 1st generation AP
Goal?
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Percent of Seroquel patientson therapeutic dose
Quarterly Summary—Comparison
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Lifeworks State
Percent of Seroquel patientson therapeutic dose
Goal?
Antipsychotics—Cost
Drug Cost*
haloperidol $23
perphenazine $45
clozapine $210
Risperdal $250
Risperdal M-Tab $310
Geodon $310
Invega $340
Abilify $440
Abilify Discmelt $450
Zyprexa $460
Seroquel (>300mg/d) $530
Zyprexa Zydis $550
*Avg retail cost for 30-days to OHP1st QTR 2007Excludes rebate
Antipsychotics—Cost
Drug Cost*
haloperidol $23
perphenazine $45
clozapine $210
Risperdal $250
Risperdal M-Tab $310
Geodon $310
Invega $340
Abilify $440
Abilify Discmelt $450
Zyprexa $460
Seroquel (>300mg/d) $530
Zyprexa Zydis $550
*Avg retail cost for 30-days to OHP1st QTR 2007Excludes rebate
DC
DC
DC
DC
Antipsychotic Dose Optimization
From October 2006 through September 2007 323 antipsychotic dose optimization change
forms have been sent Expected savings per change = $220
323 X 60% = 194 194 X $220 = $42,680 $42,680 X 12 = $512,160
Identification of Specialty Practice: Primary Care and Psychiatry
Antipsychotic Prescribing Rate—Psychiatry Specialty
0
200
400
600
800
1000
1200
1400
1600
1800
HAL PER ABIL GEO RISP SERO ZYP
Uni
que
Pat
ient
s
Antipsychotic Prescribing Rate—Psychiatry and Primary Care
0200400600800
10001200140016001800
HAL PER ABIL GEO RISP SERO ZYP
Psychiatry Primary Care
Uni
que
Pat
ient
s
Antipsychotic Prescribing Rate—Psychiatry and Primary Care
0%
5%
10%
15%
20%
25%
30%
35%
40%
HAL PER ABIL GEO RISP SERO ZYP
Psychiatry Primary Care
% P
atie
nts
Seroquel Dosing*—Psychiatry Specialty
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Dai
ly S
eroq
uel D
ose
81%
19%
*Reflects use of dose for ≥90 days
Seroquel Dosing*—Psychiatry and Primary Care
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low Dose
(<300mg)
Therapeutic Dose
(300-800mg)
High Dose
(>800mg)
Psychiatry Primary Care
Dai
ly S
eroq
uel D
ose
81%
19%
*Reflects use of dose for ≥90 days
87%
13%
Quarterly Summary—Seroquel (% of patients within therapeutic dose range)
-10% 0% 10% 20% 30% 40% 50% 60%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Psychiatry Primary Care
Quarterly Summary—RISP + PER
(% of AP use)
-10% 0% 10% 20% 30% 40% 50% 60%
2007 Q3
2007 Q2
2007 Q1
2006 Q4
Psychiatry Primary Care
Key Points
Risperdal and perphenazine are cost-effective treatment alternatives Risperdal will be generic in 2008
Seroquel is not recommended for use as a sedative/hypnotic