Û Õ iÊÌ ÀÌii ÊUÊ Õ LiÀÊi } Ì VÌ LiÀÊÓääÇ · MBA, PhD, Children ... JD, FAMCP, PrescriptionSolutions,Irvine,CA Director:Robert McMahan, PharmD, MBA, ... • For

Peer-Reviewed Journal of the Academy of Managed Care Pharmacy

677

652 LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary Heart Disease or Diabetes in a Commercial HMO

Relationship of the Magnitude of Member Cost-Share and Medication Persistence With Newly Initiated Renin Angiotensin System Blockers

Factors Associated With Choice of Pharmacy Setting Among DoD Health Care Beneficiaries Aged 65 Years or Older

Abstracts From Professional Poster Presentations at AMCP’s 2007 Educational Conference

Managed Care Pharmacy Residencies, Fellowships, and Other Programs

689

708

664

www.amcp.org Vol. 13, No. 8 October 2007 JMCP Journal of Managed Care Pharmacy 643

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All articles published represent the opinions of theauthors and do not reflect the official policy or viewsof the Academy of Managed Care Pharmacy or theauthors’ institutions unless so specified.Copyright© 2007, Academy of Managed CarePharmacy. All rights reserved. No part of thispublication may be reproduced or transmitted inany form or by any means, electronic or mechanical,without written permission from the Academy ofManaged Care Pharmacy.

C O N T E N T S

■ RESEARCH

652 LDL-C Goal Attainment Among Patients Newly Diagnosed With Coronary HeartDisease or Diabetes in a Commercial HMOSoma S. Nag, PhD; Gregory W. Daniel, RPh, MS, MPH; Michael F. Bullano, PharmD; Sachin Kamal-Bahl,PhD; Shiva G. Sajjan, PhD; X. Henry Hu, MD, PhD; and Charles Alexander, MD

664 Relationship of the Magnitude of Member Cost-Share and Medication PersistenceWith Newly Initiated Renin Angiotensin System BlockersDongmu Zhang, PhD; Angeline M. Carlson, PhD; Patrick P. Gleason, PharmD; Stephen W.Schondelmeyer, PhD; Jon C. Schommer, PhD; Bryan E. Dowd, PhD; and Alan H. Heaton, PharmD

677 Factors Associated With Choice of Pharmacy Setting Among DoD Health CareBeneficiaries Aged 65 Years or OlderAndrea Linton, MS; Mathew Garber, PhD; Nancy K. Fagan, DVM, PhD; and Michael Peterson, DVM, DrPH

Volume 13, No. 8

650 Cover ImpressionsPower Twenty in Two (2000) David BarefordSheila Macho, Cover Editor

687 Letters

689 Abstracts From Professional Poster Presentations at AMCP’s 2007Educational Conference

708 Managed Care Pharmacy Residencies, Fellowships, and Other Programs

■ DEPARTMENTS

Journal of Managed Care Pharmacy JMCP 2007 Vol. 13, No. ww.amcp.org

EDITORIAL MISSION

JMCP publishes peer-reviewed original research manuscripts, subject reviews, and other content intended to advance the use of the scientific method, including the inter-pretation of research findings in managed care pharmacy. JMCP is dedicated to improving the quality of care delivered to patients served by managed care pharmacyby providing its readers with the results of scientific investigation and evaluation of clinical, health, service, and economic outcomes of pharmacy services andpharmaceutical interventions, including formulary management. JMCP strives to engage and ve professionals in pharmacy, medicine, nursing, and related fields tooptimize the value of pharmaceutical products and pharmacy services delivered to patients. JMCP employs extensive bias-management procedures intended to ensure theintegrity and reliability of published work.

EDITORIAL ADVISORY BOARD

The JMCP Editorial Advisory Board is chaired byMarvin D. Shepherd, PhD, Center for Pharm a c oeconomic Studies,College of Pharmacy, University of Texas at Austin; Thomas Delate, PhD, Kaiser Permanente of Colorado, Aurora, serves as vice chair.

They and the other advisers review manuscripts and assist in the determination of the value and accuracy of information provided to readers of JMCP.

Carl Victor Asche, PhD, MBA, College of Pharmacy, University of Utah,Salt Lake City

John P. Barbuto, MD, HealthSouth Rehabilitation Hospital, Sandy, UTChris Bell, MS, RTI Health Solutions, Research Triangle Park, NCJoshua Benner, PharmD, ScD, ValueMedics Research, LLC, Falls Church, VAEliot Brinton, MD, School of Medicine, University of Utah, Salt Lake CityLeslee J. Budge, MBA, Kaiser Permanente, Oakland, CAScott A. Bull, PharmD, ALZA Corporation, Mt. View, CANorman V. Carroll, PhD, School of Pharmacy, Virginia Commonwealth

University, RichmondAlice Corina Ceacareanu, PhD, PharmD candidate, College of Pharmacy,

University of Tennessee, MemphisJingdong Chao, PhD, sanofi-aventis, Bridgewater, NJTara R. Cockerham, PharmD, Clinical Pharmacy Consultant, Atlanta, GAEric J. Culley, PharmD, Highmark BlueShield, Pittsburgh, PAGregory W. Daniel, RPh, MS, MPH, Pharmaceutical Economics, Policy and

Outcomes Research, University of Arizona, TucsonLisa A. Edwards, PharmD, WellPoint NextRx, North Kingstown, RILida R. Etemad, PharmD, MS, UnitedHealth Group, Edina, MNAncilla Fernandes, PhD, MedImmune, Gaithersburg, MDPatrick R. Finley, PharmD, BCPP, University of California at San FranciscoFeride Frech-Tamas, MPH, Novartis Pharmaceuticals Corp., East Hanover, NJPatrick P. Gleason, PharmD, BCPS, Prime Therapeutics, LLC, Eagan, MNCharnelda Gray, PharmD, BCPS, Kaiser Permanente, Atlanta, GAAnn S. M. Harada, PhD, MPH, Prescription Solutions, Irvine, CAMark Jackson, BScPharm, BComm, RPh, Green Shield Canada, Windsor,

OntarioStephen J. Kogut, PhD, MBA, College of Pharmacy, University of Rhode

Island, Kingston

Joanne LaFleur, PharmD, MSPH, College of Pharmacy, University of Utah,Salt Lake City

Bradley C. Martin, PharmD, PhD, College of Pharmacy, University ofArkansas, Little Rock

Christina Meyer, MHS, Caremark, Hunt Valley, MDRobert L. Ohsfeldt, PhD, School of Rural Public Health, Texas A&M Health

Science Center, College StationSteven Pepin, PharmD, BCPS, PharmWorks, LLC, Arden Hills, MNMary Jo V. Pugh, PhD, South Texas Veterans Healthcare System, San AntonioBrian J. Quilliam, PhD, RPh, College of Pharmacy, University of Rhode

Island, KingstonCathlene Richmond, PharmD, Kaiser Permanente, California Regions, OaklandElan Rubinstein, PharmD, MPH, EB Rubinstein Associates, Oak Park, CAFadia T. Shaya, PhD, MPH, School of Pharmacy, University of Maryland,

BaltimoreDenise Sokos, PharmD, BCPS, School of Pharmacy, University of

Pittsburgh, PABrent Solseng, PharmD, BlueCross BlueShield of North Dakota, FargoJoshua Spooner, PharmD, MS, Advanced Concepts Institute, Philadelphia, PAMarilyn Stebbins, PharmD, CHW Medical Foundation, Rancho Cordova, CA;

University of California, San FranciscoKent H. Summers, RPh, PhD, School of Pharmacy, Purdue University,

Lafayette, INSheryl L. Szeinbach, PhD, College of Pharmacy, Ohio State University,

ColumbusRobert J. Valuck, RPh, PhD, School of Pharmacy, University of Colorado

Health Sciences Center, DenverRichard A. Zabinski, PharmD, United Health Group, Golden Valley, MN

(President, AMCP Board of Directors: liaison to the JMCP EditorialAdvisory Board)

Managing Editor, Jamie Kunkle, MA, (703) 671-1358,[email protected]

Associate Editor, Kathleen A. Fairman, MA, (602) 867-1343,[email protected]

Assistant Editor, Diane P. Britton, (703) 323-0454, [email protected]

Peer Review Administrator, Jennifer A. Booker, (703) 317-0725,[email protected]

Graphic Designer, Kathleen Furey, Furey DesignCover Editor, Sheila Macho, (952) 431-5993, [email protected]

EDITORIAL STAFF

Editor-in-ChiefFrederic R. Curtiss, PhD, RPh, CEBS

(830) 935-4319, [email protected]

PublisherJudith A. Cahill, CEBS, Executive Director, Academy of Managed Care Pharmacy

Journal of Managed Care Pharmacy (ISSN 1083–4087) is published 9 times per year and is the official publication of the Academy of Managed Care Pharmacy (AMCP),100 North Pitt St., Suite 400, Alexandria, VA 22314; (703) 683-8416; (800) TAP-AMCP; (703) 683-8417 (fax). The paper used by the Journal of Managed Care Pharmacy meetsthe requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper) effective with Volume 7, Issue 5, 2001; prior to that issue, all paper was acid-free. Annual membership duesfor AMCP include $60 allocated for theJournal of Managed Care Pharmacy. POSTMASTER: Send address changes to JMCP, 100 North Pitt St., Suite 400, Alexandria, VA 22314.

6 48 8 w October

ser

■■ Editorial Content and Peer ReviewAll articles, editorials, and commentary inJMCP undergo peer review; articles under-go blinded peer review. Letters may bepeer reviewed to ensure accuracy. Thefundamental departments for manuscriptsubmission are:

• Research• Subject Reviews• FormularyManagement• Contemporary Subjects• Brief Communications• Editorials/Commentary• LettersAll submissions other than Editorials,

Commentary, and Letters, should includean abstract and inform the reader at theend of the manuscript of what is alreadyknown about the subject and what thearticle adds to our knowledge of the subject.

For manuscript preparation requirements,see “JMCP Author Guidelines” in this Journalor at www.amcp.org.

■■ ResearchThese are well-referenced articles basedon original research that has not beenpublished elsewhere and reflects use ofthe scientific method. The research isguided by explicit hypotheses that arestated clearly by the authors.

■■ Subject ReviewsThese are well-referenced, comprehensivereviews of subjects relevant to managedcare pharmacy. The Methods section in theabstract and in the body of the manuscriptshould make clear to the reader the sourceof the material used in the review, includingthe criteria used for inclusion and exclusionof information.

■■ Formulary ManagementThese are well-referenced, comprehensivereviews of subjects relevant to formularymanagement methods or procedures in theconduct of pharmacy and therapeutics (P&T)committees and may include description andinterpretation of clinical evidence.

■■ Contemporary SubjectsThese are well-referenced submissions thatare particularly timely or describe researchconducted in pilot projects. ContemporarySubjects, like all articles in JMCP, mustdescribe the hypothesis or hypotheses thatguided the research, the principal methods,and results.

■■ Brief CommunicationsThe results of a small study or a descriptiveanalysis that does not fit in other JMCPdepartments may be submitted as a BriefCommunication.

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Employees of advertisers may submitarticles for publication in the editorialsections of JMCP, subject to the usualpeer-review process. Financial disclosure,

JMCP EDITORIAL POLICY

EDITORIAL MISS ION AND POLIC IES

JM CP publishes peer-reviewed original research manuscripts, subject reviews, and othercontent intended to advance the use of the scientific method, including the interpreta-tion of research findings in managed care pharmacy. JM CP is dedicated to improving thequality of care delivered to patients served by managed care pharmacy by providing itsreaders with the results of scientific investigation and evaluation of clinical, health,service, and economic outcomes of pharmacy services and pharmaceutical interven-tions, including formulary management. JM CP strives to engage and serve professionalsin pharmacy, medicine, nursing, and related fields to optimize the value of pharmaceu-tical products and pharmacy services delivered to patients.

JMCP employs extensive bias-management procedures that include (a) full disclosureof all sources of potential bias and conflicts of interest, nonfinancial as well as finan-cial; (b) full disclosure of potential conflicts of interest by reviewers as well as authors;and (c) accurate attribution of each author’s contribution to the article. Aggressivebias-management methods are necessary to ensure the integrity and reliability ofpublished work.

Editorial content is determined by the Editor-in-Chief with suggestions fromthe Editorial Advisory Board. The views and opinions expressed in JM CP do notnecessarily reflect or represent official policy of the Academy of Managed CarePharmacy or the authors’ institutions unless specifically stated.

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See “Advertising Opportunities” atwww.amcp.org. Contact the AdvertisingRepresentative to receive a Media Kit.

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JMCP accepts for consideration manuscripts preparedaccording to the Uniform Requirements for ManuscriptsSubmitted to Biomedical Journals.1

■■ Manuscript PreparationManuscripts should include, in this order: title page,abstract, text, references, tables, and figures (seeSubmission Checklist for details).

JMCP abstracts should be carefully written narra-tives that contain all of the principal quantitative andqualitative findings, with the outcomes of statisticaltests of comparisons where appropriate. Abstracts arerequired for all articles in Research, Subject Reviews,Formulary Management, Contem-porary Subjects,and Brief Communications. The format for theabstract is Background, Objective, Methods, Results,Conclusion, Keywords. Editorials and Commentarydo not require an abstract but should include refer-ences. Letters do not require an abstract.

For descriptions of editorial content, see “JMCPEditorial Policy” in this Journal or at ww.amcp.org.

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• Most articles, particularly Subject Reviews, should incorporate or at least acknowledge the relevant work of others published previously in JMCP (see “Article Index by Subject Category” at www.amcp.org).

• For most articles in JMCP, a flowchart is recom-mended for making the effects of the inclusion and exclusion criteria clear to readers (see JMCP examplesin 2007; 13(3):237 (Figure 1), or 2007;13(1):22 (Figure 1), or 2006;12(3):234 (Table 3).

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• Many articles involve research that may pose a threatto either patient safety or privacy. It is the responsibilityof the principal author to ensure that the manuscriptis submitted with either the result of review by theappropriate institutional review board (IRB) or a state-ment of why the research is exempt from IRB review(see JMCP Policy for Protecting Patient Safety andPrivacy at www.amcp.org).

■■ Reference StyleReferences should be prepared following modifiedAMA style. All reference numbers in the manuscriptshould be superscript (e.g., 1 ). Each unique referenceshould have only one reference number. If that refer-ence is cited more than once in the manuscript, thesame number should be used. Do not use ibid or opcit for JMCP references. Please provide Web addressesfor references whenever possible. See the followingexamples of common types of references: 1. Standard journal article(List all authors when 6 or less; if more than 6, listonly the first 3 and add et al.) Stacy J, Shaw E, Arledge MD, et al. Pharmacoeconomicmodeling of prior-authorization intervention for COX-2specific inhibitors in a 3-tier copay plan. J Manag CarePharm. 2003;9(4): 327-34. Available at: http://www.amcp.org/data/jmcp/Research-327-334.pdf. AccessedFebruary 22, 2007.

2. No author givenWhen should routine screening for breast cancer start?BMJ. 2007;334(7597):769.3. Journal paginated by issueCorrigan PW, Luchins DJ, Malan RD, Harris J. User-friendly CQI for the mental health team. Med Interface.December 1994;7:89-92, 95.4. Book or monograph by authors Gold M, Siegel JE, Russell LB, et al. Cost-Effectiveness inHealth and Medicine. New York: Oxford UniversityPress; 1996.5. Book or monograph with editor, compiler, orchairman as authorChernow B, ed. Critical Care Pharmacotherapy.Baltimore, MD: Williams & Wilkins; 1995.6. Chapter in a bookKreter B, Michael KA, DiPiro JT. Antimicrobial prophy-laxis in surgery. In: DiPiro JT, Talbert RL, Hayes PE, Yee GC, Matzke GR, Posey LM, eds. Pharmacotherapy:A Pathophysiologic Approach. Norwalk, CT: Appleton & Lange; 1992:1811-12.7. Government agency publication a. Agency for Health Research and Quality. Comparativeeffectiveness of angiotensin-converting enzyme inhibitors(ACEIs) and angiotensin II receptor antagonists (ARBs)for treating hypertension. Available at: http://effective-healthcare.ahrq.gov/repFiles/ACEIs_v_ARBs_Draft_Report.pdf. Accessed February 12, 2007.b. Akutsu T. Total Heart Replacement Device. Bethesda,MD: National Institutes of Health, National Heart andLung Institute; 1974 Apr. Report no.: NIHNHLI-69-2185-84.8. Paper (or Poster) presented at a meetingColmenero F, Sullivan SD, Watkins JB, Neumann PJ.Quality of clinical and economic information in evidencedossiers submitted to managed care plans in the UnitedStates. Poster presented at: 2005 ISPOR Annual Inter-national Meeting; May 15-18, 2005; Arlington, VA.9. NewspaperWinslow R. Lipitor prescriptions surge in wake of bigstudy. Wall Street Journal. March 18, 2004:D4.10. Web siteNational Committee for Quality Assurance. The state ofhealth care quality: 2004. Industry trends and analysis.Available at: http://www.ncqa.org/communications/SOMC/SOHC2004.pdf. Accessed December 26, 2004.

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All manuscripts are reviewed prior to peer review.Manuscripts may be returned to authors prior to peerreview for clarification or other revisions. Peer reviewgenerally requires 4 weeks but may extend as long as 12 weeks in unusual cases. Solicited manuscripts aresubject to the same peer-review standards and editorialpolicy as unsolicited manuscripts.

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spacing, including

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Submit referenced tables and figures on separate pages

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For “Manuscript Submission Checklist” and “Peer Review

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REFERENCE

1. International Committee of Medical Journal Editors.Uniform requirements for manuscripts submitted to biomedical journals: writing and editing for biomedical publication. Updated February 2006. Available at:http://www.icmje.org/. Accessed April 14, 2007.

The Journal of Managed Care Pharmacy including supplements, is indexed by MEDLINE/PubMed, the International Pharmaceutical Abstracts (IPA),Science Citation Index Expanded (SCIE), Current

Contents/Clinical Medicine (CC/CM), and Scopus.

JMCP Author Guidelines

www.amcp.org Vol. 13, No. ber 2007 JMCP Journal of Managed Care Pharmacy 5168 Octo

652 Journal of Managed Care Pharmacy JMCP Octoberr 2007 Vol. 13, No. 8 www.amcp.org

ReseaRch

Background: Patients beginning treatment with lipid-modifying drugsshould have their serum lipid levels monitored and, if necessary, their drugtherapy adjusted to reach and maintain their treatment goals. Patients withcoronary heart disease or diabetes are at high risk of coronary events and areparticularly important target groups for monitoring and dose adjustment oflipid-modifying drug therapy.

oBjective: to determine from administrative claims the rates of lipid testing,treatment with low-density lipoprotein cholesterol (LdL-c)-lowering drugtherapy, and LdL-c goal attainment defined as LdL-c < 100 mg per dL inthe time period after a new diagnosis of coronary heart disease or diabetesamong patients who had not previously received lipid-modifying drug therapy.

Methods: an index date was defined by a new diagnosis of coronary heartdisease or diabetes between january 1, 1999 and december 31, 2000,preceded by a 12-month pre-index period without lipid-modifying drug treat-ment in a commercial health maintenance organization (hMo) database forthe southeastern united states. coronary heart disease (chd) was definedby a diagnosis code for myocardial infarction (International Classificationof Diseases, Ninth Edition, Clinical Modification [icd-9-cM] code 410.xx) orangina/ischemic heart disease (411.xx), or a procedural code for angioplasty(icd-9-cM 36.1x-36.3x; Current Procedural Terminology [cPt] 92980-92984,92995-92996) or coronary artery bypass graft (icd-9-cM 36.01, 36.02, 36.05,36.09; cPt 33510-33545). diabetes was identified either by an icd-9-cMdiagnosis code 250.xx or a pharmacy claim for an anti-hyperglycemicmedication. Patients were followed in the post-index period until loss ofeligibility or a maximum of 42 months (mean = 26 months, range=12-42months). We calculated the proportion of patients with lipids treated and atLdL-c goal (defined as LdL-c < 100 mg per dL) in months 1-6 after the indexdate. among those not at goal in months 1-6, we estimated the proportiontreated to goal in months 7-12 and in month 7 to the end of the post-indexperiod. Logistic regression was used to estimate the odds of goal attainmentin months 7-12 and in month 7 to the end of the post-index period amongpatients who were not at goal in months 1-6.

resuLts: Laboratory lipid values were available for 4,676 (40.4%) of 11,552patients who had not previously received lipid-modifying drug therapy inmonths 1-6 after the index date, of whom 72.7% (n = 3,400) had an LdL-c≥ 100 mg per dL (63.5% for chd and 76.7% for diabetes). of 1,245 patientstested and treated with lipid-modifying therapy in months 1-6, 485 (39.0%)were at LdL-c goal in months 1-6 (48.2% of chd and 28.8% of diabetespatients), and 760 (61.0%) were not at LdL-c goal (51.8% of those with chdand 71.2% of those with diabetes). goal attainment (cumulative) among thosetreated improved to 50.1% in months 7-12 and 58.4% in month 7 to the endof the post-index period. Patients not attaining goal in months 1-6, and whocontinued treatment in months 7-12 and month 13 to the end of the post-in-dex period, had a 48.8% (95% confidence interval [ci],44.0%-53.6%) predict-ed probability of attaining their goals. the odds of goal attainment in month 7to the end of post-index period (among those not at goal in months 1-6) weregreater for (a) age ≥ 65 years (odds ratio [or] = 2.45, 95% ci,1.62-3.72), (b)history of hypertension (or = 1.91, 95% ci, 1.20-3.03), (c) greater number ofdistinct medications (or = 1.07, 95% ci,1.01-1.14 per additional medication),(d) months of observation post-index (or = 1.04, 95% ci = 1.01-1.08 per ad-

LdL-c goal attainment among Patients newly diagnosedWith coronary heart disease or diabetes in a commercial hMo

soma s. Nag, PhD; Gregory W. Daniel, RPh, Ms, MPh; Michael F. Bullano, PharmD;sachin Kamal-Bahl, PhD; shiva G. sajjan, PhD; X. henry hu, MD, PhD; and charles alexander, MD

ReseaRch

ditional month), and (e) months supply of lipid-modifying medication(or = 1.04, 95% ci, 1.01-1.07 per additional month), and were lower forLdL-c ≥ 130 mg per dL in months 1-6 (or = 0.53, 95% ci, 0.35-0.82) and ahistory of dyslipidemia (or = 0.54, 95% ci,0.35-0.83). the odds of LdL-c goalattainment were not affected by diagnosis (chd vs. diabetes), gender, statintitration (34% of patients), lipid-modifying drug switching (39% of patients),or treatment with a high-potency LdL-c-lowering drug dosage(one of sufficient strength to reduce LdL-c by > 40%).

concLusion: of patients receiving lipid testing and lipid drug treatment inthe 6 months after an initial diagnosis of chd or diabetes, 61% were not atthe LdL-c goal of < 100 mg per dL. among those not at LdL-c goal in the first6 months of treatment, only about half who continued treatment subsequentlyattained their LdL-c goal, despite statin titration or switching of their lipid-modifying drug therapy.

keyWords. coronary heart disease, diabetes, goal attainment, Lipidtreatment

J Manag Care Pharm. 2007;13(8):652-663Copyright© 2007, Academy of Managed Care Pharmacy. All rights reserved.

What is already known about this subject

What this study adds

• The LDL-C goal attainment rate for a national sample of patientswith coronary heart disease (CHD) in 2003 was 62%.

• National surveys and cross-sectional studies of diabetic patientsin managed care reported a lipid-modifying drug treatment rateof 28% in 1999-2000 and LDL-C goal (<100 mg per dL) attain-ment rates of 32-55% in 1999-2003. The 2003 HealthcareEffectiveness Data and Information Set (HEDIS) average LDL-Cgoal (<100 mg per dL) attainment rate for diabetes in partici-pating commercial health plans was 35%, which improved to44% in 2005.

• While these cross-sectional studies provide snapshots of lipidmanagement at points in time, not enough is known about therates of LDL-C goal attainment in the months after firstdiagnosis of CHD or diabetes.

• Of those who were tested and treated for LDL-C in the first 6months after an initial diagnosis of CHD or diabetes, 39.0%(CHD 48%, diabetes 29%) were at LDL-C goal <100 mg per dL.

• Cumulative goal attainment among those continuing treatmentimproved to 50% in the second 6 months and to 58% over 26months of follow-up.

• Patients who were treated but not at LDL-C <100 mg per dL inthe first 6 months after diagnosis and who continued treatmentwith lipid-modifying drugs had only about a 50% probability ofsubsequently attaining LDL-C goal regardless of CHD or diabetesdiagnosis.

aBsTRacT


LDL-C Goal Attainment Among Patients Newly DiagnosedWith Coronary Heart Disease or Diabetes in a Commercial HMO

Both the National Cholesterol Education Program (NCEP)and the American Diabetes Association (ADA) guide-lines now recommend treating patients with coronary

heart disease (CHD) or diabetes to a low-density lipoprotein-cholesterol (LDL-C) goal of < 100 mg per dL.1,2 The goal ofLDL-C < 100 mg per dL was first defined for CHD in 1994 bythe NCEP Adult Treatment Panel II (ATP II), and for diabe-tes by the ADA in 1998.3,4 The NCEP Third Adult TreatmentPanel (ATP III) in 2001 assigned diabetes CHD risk equivalence,and an LDL-C goal of < 100 mg per dL was adopted.1 Despitethe guidelines, there is considerable evidence of inadequateLDL-Cgoal attainment inclinicalpractice.5-18 Nationwide in2003,LDL-C goal attainment was 57% for patients with CHD, diabetes,or CHD risk equivalence, compared with 89% for patients in thezero CHD risk factor category.18 There is, however, little informa-tion about the likelihood of attaining LDL-C goal in the monthsimmediately after CHD or diabetes diagnosis.

In this study, LDL-C goal attainment in the months afterdiagnosis of CHD or diabetes (diagnosis by medical claim codeor pharmacy claim for an anti-hyperglycemic drug) in patientsbeginning treatment with lipid-modifying drugs was examined.

nn METHODSStudy design and patient selectionThis was a retrospective cohort study using administrative claimsdata in the HealthCore Integrated Research Database for theperiod January 1, 1998 through June 30, 2002. The data setused was from the commercial health maintenance organization(HMO) portion of a southeastern United States managed careorganization (MCO). Electronic records of laboratory valueswere obtained from a single national laboratory provider undercontract to this HMO. The initial study database included datafor approximately 1.1 million members in which all MCOeligibility, medical, and pharmacy files were linked by memberidentification number to electronic records of laboratory valuesfrom the single national provider. The database did not includelaboratory tests conducted in inpatient or outpatient hospitalsettings or in physician offices (i.e., the laboratory values weremissing from the database for any facility or physician that didnot outsource testing to the single national laboratory provider).

Patients’ identities were masked throughout the studyin a limited data set format, in accordance with the HealthInsurance Portability and Accountability Act (HIPAA) of 1996.Institutional review board approval was not sought, because therewas no patient intervention and the limited data were utilized inaccordance with appropriate data use agreements with thecovered entities as defined in HIPAA.

Patients with CHD or diabetes were identified during anindex period from January 1, 1999 through December 31, 2000by diagnosis or procedure codes on at least 1 medical or hospitalclaim, or receipt of at least 1 pharmacy claim for an anti-hyper-glycemic drug. The International Classification of Diseases, Ninth

Revision, Clinical Modification (ICD 9-CM) codes in any diagnosisfield, or Current Procedural Terminology, version 4 (CPT-4),codes on an inpatient or outpatient claim were used to identifyCHD: myocardial infarction (ICD 9-CM 410.xx) or angina/isch-emic heart disease (411.xx), or a procedural code for angioplasty(ICD-9-CM 36.1x-36.3x; CPT 92980-92984, 92995-92996) orcoronary artery bypass graft (ICD-9-CM 36.01, 36.02, 36.05,36.09; CPT 33510-33545). Diabetes was identified by diagnos-tic codes ICD-9-CM 250.xx or at least 1 pharmacy claim for ananti-hyperglycemic medication, defined by Generic ProductIdentifier (GPI) codes (Medi-Span, Master Drug Database;2003). GPI-4 codes for anti-diabetic drugs were: insulins 2710,sulfonylureas 2720, anti-diabetic amino acid derivatives 2723,biguanides 2725, meglitinide analogues 2728, alpha glucosidaseinhibitors 2750, insulin sensitizing agents 2760, andanti-diabetic combinations 2799.

The index date was defined as the date of the first claim witha diagnosis or procedure code for CHD, a diagnosis code fordiabetes, or a pharmacy claim for an anti-hyperglycemic drug.Continuous plan eligibility was required for at least 12 monthsbefore and after the index date (the 12-month pre-index andpost-index periods). Patients were excluded if they had anencounter claim coded with CHD or diabetes, or if they receiveda lipid-lowering medication, during the 12-month pre-indexperiod. Since the goal of this study was to examine LDL-C goalattainment following an incident diagnosis of CHD or diabetesamong patients previously untreated with lipid-modifyingmedications, a lipid-lowering medication in the pre-indexperiod was a criterion for exclusion. A diagnosis of dyslipidemiawas not a reason for exclusion, provided there was no evidenceof lipid-modifying drug treatment. Dyslipidemia was regardedas a potentially confounding variable and it was included as acovariate in the regression model.

Only patients with electronic laboratory data available in theHealthCore Integrated Research Database in the 12-monthpre-index and post-index periods were retained for furtheranalysis. Sixty-one patients with initial diagnoses for both CHDand diabetes on the index date (i.e., on the same day)were excluded as potentially spurious data. The sample selec-tion steps are shown in Figure 1, and the study periods areillustrated in Figure 2.

Study variablesLipid testing, treatment, and LDL-C goal attainment wereeach determined within 3 time periods after the index date:months 1-6, months 7-12, and month 7 to the end of thepost-index period (Figure 2). LDL-C testing was determinedby the presence of 1 or more LDL-C or lipid panel values inthe electronic database of laboratory results. These values wererecorded using either Logical Observation Identifiers Namesand Codes (LOINC) or actual test names. The laboratory recordsincluded the date of testing. LDL-C values were calculated


654 Journal of Managed Care Pharmacy JMCP October 2007 Vol. 13, No. 8 www.amcp.org

using the Friedewald formula, which computes LDL-Cfrom the equation:

TC – HDL-C – TG/5,where TC, HDL-C, and TG are the plasma concentrationsof total cholesterol, high-density lipoprotein-cholester-ol, and triglycerides, respectively,19 or obtained directly iftriglycerides were> 400 mg per dL. (The Friedewald formula isunable to calculate LDL-C for patients whose triglycerides exceed400 mg/dL.) LDL-C goal attainment was defined as LDL-C <100mg per dL. The lowest LDL C value was used for patients withmore than 1 LDL-C measurement within any of the post-indextime periods.

Use of lipid-lowering medication was determined from phar-macy claims with GPI-4 codes 3940, 3910, 3920, and 3945 for3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhib-itors (“statins”), bile acid sequestrants, fibric acid derivatives,and nicotinic acid derivatives, respectively. Patients were consid-ered to be on lipid-lowering therapy during months 1-6 after theindex date if they had at least 1 pharmacy claim for anylipid-modifying medication during that time period. For patientswho were not at LDL-C goal in months 1-6 and who continueddrug treatment, we examined LDL-C goal attainment in months7-12 and in month 7 to the end of the post-index period.Patients were defined as treated during months 7-12 if theyreceived at least 1 pharmacy claim for any lipid-modifyingmedication in months 1-6 and in months 7-12. Patients weredefined as treated from month 7 to the end of the post-indexperiod if they received at least 1 pharmacy claim for any lipid-modifying medication in each of the 3 following time periods:months 1-6, months 7-12, and month 13 to the end of the post-index period. Table 1 summarizes the identification ofpatients whose lipids were tested and who were treated withlipid-modifying drugs.

High-potency LDL-C treatment was defined as a lipid-lower-ing drug dosage of sufficient strength to reduce LDL-C by> 40%,which included simvastatin 40 mg or higher, atorvastatin 20 mgor higher, or rosuvastatin 10 mg or higher. History ofhypertension (ICD-9-CM 401.xx and a pharmacy claim for anantihypertensive medication) and dyslipidemia (ICD-9-CM 272.xx) were determined during the 12-month pre-indexperiod. Antihypertensive medication categories included anti-hypertensives (GPI-2 code 36: GPI-4 codes 3610 [angiotensin-converting enzyme inhibitors], 3615 [angiotension II receptorblockers], 3620 [adrenolytic antihypertensives includingalpha blockers], 3640 [vasodilators], 3660 [miscellaneousantihypertensives], and 3699 [antihypertensive combinations]),beta-blockers (GPI-2 code 33: GPI-4 code 3310 [nonselectivebeta-blockers], 3320 [cardio-selective beta-blockers], and 3330[alpha beta-blockers]), calcium channel blockers (GPI-2 code34), potassium sparing diuretics (GPI-4 code 3750), thiazidediuretics (GPI-4 code 3760), and combination diuretics (GPI-4code 3799). The number of distinct medications was determined

FIGURE 1 Sample Selection of Patients Includedin Analysis

(n = 17,287 [15.7%])

CHD or diabetes diagnosis(ICD-9-CM code)

Patients 30 years

Exclude patients with both new

Patients with minimum12 months pre- andpost-index eligibility(n = 33,007 [30.0%])

(n = 19,098 [17.4%])

(n = 19,070 [17.4%])

(n = 15,877 [14.4%])

(N = 109,906)

Patients with at least 1 CHD ordiabetes claim with dates ofservice in 1999 or 2000

Exclude patients with prior

(n = 11,613 [10.6%])

CHD and DM on index date(ICD-9, CPT, GPI-4)

Exclude patients with prior CHD

Exclude patients with prior

or diabetes diagnosis (CPT code)

anti-diabetic drug (GPI-4 code)

(n = 11,552 [10.5%])

fill in 12-month pre-index period (GPI-4)Patients with no lipid-modifying medication

Sample population(N 1.1 million)

Exclude patients without laboratoryresults during 12-month pre- and

post-index periods(n = 16,251 [14.8%])

>

CHD = coronary heart disease; ICD-9-CM = International Classification of Diseases,Ninth Edition, Clinical Modification; CPT = Current Procedural Terminology;DM = diabetes mellitus. CHD defined by ICD-9-CM codes 410.xx, 411.xx,36.1x-36.3x, 36.01, 36.02, 36.05, or 36.09, or CPT-4 codes 92980-92984,92995-92996, or 33510-33545. Diabetes defined by ICD-9-CM code 250.xx orMedi-Span Generic Product Identifier (GPI) codes that start with 2710, 2720, 2723,2725, 2728, 2750, 2760, or 2799. Lipid-modifying medication defined by GPI codesthat start with 3940, 3910, 3920, or 3945.



at the drug class level from the number of unique 2-characterGPI codes for all drugs, including both acute and chronicmedications (e.g., 01 for penicillins; 02 for cephalosporins; 33for beta-blockers; 34 for calcium channel blockers; and 36 forangiotensin-converting enzyme [ACE] inhibitors, angiotensin IIreceptor blocker [ARBs], and other antihpertensives) during the12-month pre-index period.

Statistical methodsThe characteristics of patients newly diagnosed with CHD

and diabetes were compared using descriptive statistics. Thestatistical significance of differences between these 2 patient setswas determined using an independent t test for continuousvariables and Pearson chi-square tests for nominal/categoricalvariables. Rates of lipid treatment and LDL-C goal attainment inmonths 1-6 were examined with descriptive analyses. Weapplied logistic regression to estimate the odds of LDL-C goalattainment in months 7-12 and from month 7 to the end of thepost-index period among patients who did not attain LDL-Cgoal in months 1-6. The outcome for each model was binary,with attaining the LDL-C goal set to 1 and not attaining the goalset to 0. Odds ratios for all model covariates were calculated byexponentiating the logistic regression coefficients. The sample

used for model estimation was limited to patients with LDL-C,HDL-C, and triglyceride measurements in months 1-6. Variablesentered into the models were chosen a priori based on clinicalrelevance and forced into the final models regardless of statisti-cal significance. These variables included age, sex, histories ofhypertension and dyslipidemia, CHD or diabetes status, lipidvalues (LDL-C ≥ 130 mg per dL, HDL-C < 40 mg per dL, andtriglycerides ≥ 200 mg per dL) in months 1-6, adjustments tolipid therapy (statin titration, switching), use of high-potencyLDL-lowering statin dosages, the number of days supply oflipid-modifying drugs, and the number of distinct prescriptionmedications. The number of distinct prescription medicationsis an adjustment for comorbidity burden that has beenvalidated.20,21 Regression model fit was assessed using the Hos-mer-Lemeshow goodness-of-fit test and discrimination wasmeasured by examining the area under the ROC curve.22 To cal-culate overall predicted probability of goal attainment, meanvalues on all covariates were calculated and inserted into thelogistic regression equation (i.e., multiplied by the logistic re-gression coefficients).23 As is standard in logistic regression, theresulting linear predictor (natural log of the odds) was convertedinto an overall probability using the formula:

eZ / (1+eZ),

FIGURE 2 Schematic of Study Periods

Jan 1, 1998 Jan 1, 1999 Dec 31, 2000 June 30, 2002

Index date

12-month post-indexperiod

12-month pre-indexperiod

Overall study period

Index period

Month 7 to end ofpost-index period

Month 12Month 6

Months 1-6

Months 7-12





where e is the base of natural logarithms and Z is the linearpredictor. This calculation was performed for the sample overalland for each of the 2 patient sets (CHD and diabetes).

Statin titration was defined as an increase in the strength ofthe dispensed statin. A switch was defined as a claim for anylipid drug (statin or nonstatin) different from the previous lipiddrug fill, with no subsequent claim for the original drug. Forthe regression model that predicted LDL-C goal attainmentin months 7-12, the titration and switching variables weredetermined for months 1-12. For the model that predicted goalattainment in month 7 to the end of the post-index period, the

titration and switching variables were determined for month1 to the end of the post-index period. The number of monthsin the post-index period was included in the model for goalattainment in month 7 to the end of the post-index period, toadjust for unequal duration of follow-up among patients.

The number of days supply was aggregated for all statins.A small fraction of patients were treated only with nonstatins(5.9% of patients in months 1-6; 4.5% of patients in months7-12; and 3.6% of patients in month 7 to the end of the studyperiod). Since days supply was not captured for patients treatedonly with nonstatins, it was imputed based on an adjusted days

TABLE 1 Identification of Tested and Treated Patients

Variable Measured Definition Time Period(s)

Number of Cases

All CHD Diabetes

Number of patientsCoronary heart* disease or

diabetes†Index period Jan 1,

1999 to Dec 31, 2000

11,552 3,320 8,232

Lipid test by national

laboratory provider

LDL-C test result - field occupied months 1-6 4,676 1,418 3,258

Patients at goal –

treated and not treated

LDL-C <100 mg per dL months 1-6 1,276 518 758

Patients not at LDL-C

goal

LDL-C > 100 mg per dL months 1-6 3,400 900 2,500

Patients treated with

lipid-lowering drug‡Any lipid-lowering drug therapy months 1-6 1,742 886 856

Patients tested and

treated§LDL-C test result - field occupied;

and 1 or more pharmacy claims

for lipid-modifying drug

months 1-6 1,245 651 594

Patients treated and at

goal

LDL-C test result <100 mg per dL months 1-6 39.0%

485

48.2%

314

28.8%

171

Patients tested and

treated§ and not at

goal

1 or more pharmacy claims for

lipid-modifying drug and LDL-C >100 mg per dL

months 1-6 61.0%

760

51.8%

337

71.2%

423

Patients with continued

treatment in months

7-12

LDL-C test result field occupied;


for a lipid-modifying drug in eachtime period‡

months 1-6 and

months 7-12

48.2%

600

42.9%%

279

54.0%

321


treatment from month

7 to end of post-index

period



for a lipid-modifying drug in each

time period‡

months 1-6 and

months 7-12 and

month 13 to end of

post-index period

39.8%

496

36.1%

235

43.9%

261

*International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) 410.xx, 411.xx, 36.1x-36.3x, 36.01, 36.02, 36.05, or 36.09;or Current Procedural Terminology (CPT-4) 92980-92984, 92995-92996, or 33510-33545.†ICD-9-CM 250.xx; or Medi-Span Generic Product Identifier (GPI) codes that start with 2710, 2720, 2723, 2725, 2728, 2750, 2760, or 2799.‡The proportion of patients with baseline LDL-C > 100 mg per dL was not measured (i.e., some of these patients treated with lipid-lowering drug therapy could have hadLDL-C < 100 mg per dL at baseline).§The relative timing of testing and treatment within any time period was not captured.GPI codes that start with 3940, 3910, 3920, or 3945.

All

11,552

4,676

1,276

3,400

1,742

1,245

39.0%

485

61.0%

760

48.2%

600

39.8%

496

LDL-C = low-density lipoprotein-cholesterol; CHD = coronary heart disease.

Authors



where e is the base of natural logarithms and Z is the linearpredictor. This calculation was performed for the sample overalland for each of the 2 patient sets (CHD and diabetes).

Statin titration was defined as an increase in the strength ofthe dispensed statin. A switch was defined as a claim for anylipid drug (statin or nonstatin) different from the previous lipiddrug fill, with no subsequent claim for the original drug. Forthe regression model that predicted LDL-C goal attainmentin months 7-12, the titration and switching variables weredetermined for months 1-12. For the model that predicted goalattainment in month 7 to the end of the post-index period, the

titration and switching variables were determined for month1 to the end of the post-index period. The number of monthsin the post-index period was included in the model for goalattainment in month 7 to the end of the post-index period, toadjust for unequal duration of follow-up among patients.

The number of days supply was aggregated for all statins.A small fraction of patients were treated only with nonstatins(5.9% of patients in months 1-6; 4.5% of patients in months7-12; and 3.6% of patients in month 7 to the end of the studyperiod). Since days supply was not captured for patients treatedonly with nonstatins, it was imputed based on an adjusted days

TABLE 1 Identification of Tested and Treated Patients

Variable Measured Definition Time Period(s)

Number of Cases

All CHD Diabetes

Number of patientsCoronary heart* disease or

diabetes†Index period Jan 1,

1999 to Dec 31, 2000

11,552 3,320 8,232

Lipid test by national

laboratory provider

LDL-C test result - field occupied months 1-6 4,676 1,418 3,258

Patients at goal –

treated and not treated

LDL-C <100 mg per dL months 1-6 1,276 518 758

Patients not at LDL-C

goal

LDL-C > 100 mg per dL months 1-6 3,400 900 2,500

Patients treated with

lipid-lowering drug‡Any lipid-lowering drug therapy months 1-6 1,742 886 856

Patients tested and

treated§LDL-C test result - field occupied;


for lipid-modifying drug

months 1-6 1,245 651 594

Patients treated and at

goal

LDL-C test result <100 mg per dL months 1-6 39.0%

485

48.2%

314

28.8%

171

Patients tested and

treated§ and not at

goal

1 or more pharmacy claims for

lipid-modifying drug and LDL-C >100 mg per dL

months 1-6 61.0%

760

51.8%

337

71.2%

423


treatment in months

7-12



for a lipid-modifying drug in eachtime period‡

months 1-6 and

months 7-12

48.2%

600

42.9%%

279

54.0%

321


treatment from month

7 to end of post-index

period



for a lipid-modifying drug in each

time period‡

months 1-6 and

months 7-12 and

month 13 to end of

post-index period

39.8%

496

36.1%

235

43.9%

261

*International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) 410.xx, 411.xx, 36.1x-36.3x, 36.01, 36.02, 36.05, or 36.09;or Current Procedural Terminology (CPT-4) 92980-92984, 92995-92996, or 33510-33545.†ICD-9-CM 250.xx; or Medi-Span Generic Product Identifier (GPI) codes that start with 2710, 2720, 2723, 2725, 2728, 2750, 2760, or 2799.‡The proportion of patients with baseline LDL-C > 100 mg per dL was not measured (i.e., some of these patients treated with lipid-lowering drug therapy could have hadLDL-C < 100 mg per dL at baseline).§The relative timing of testing and treatment within any time period was not captured.GPI codes that start with 3940, 3910, 3920, or 3945.

All

11,552

4,676

1,276

3,400

1,742

1,245

39.0%

485

61.0%

760

48.2%

600

39.8%

496

LDL-C = low-density lipoprotein-cholesterol; CHD = coronary heart disease.

Authors



supply for statins. An ordinary least squares regression modelwas run for statin users who were not at goal in months 1-6: dayssupply =β0 +β1 (CHD vs. diabetes)+ β2 (age) + β3 (sex)+ε. Themodel estimates were then used to predict days supply for non-statin users. Separate regressions estimated the days supply formonths 1-12 and for the entire post-index period. The observeddays supply for the statin users and the imputed days supplyfor the nonstatin users were then entered (as months supply)into the regression models of LDL-C goal attainment. An a priori2-tailed level of significance was set at the 0.05 level. All analyseswere carried out using Stata version 8.2 (Stata Corporation, Inc.,College Station, TX).

nn RESULTSMost of the 11,522 patients who met the study inclusion criteriawere newly diagnosed with diabetes (71%), the remaining 29%being newly diagnosed with CHD. Compared with patients withdiabetes, those with CHD were significantly older and includeda higher proportion of males (Table 2). The duration of the post-index period was similar for both cohorts, with an overall meanof 26 months (range 12-42 months). The proportions of patientswith histories of hypertension and dyslipidemia were higher forpatients with newly diagnosed CHD than for those with diabetes(38% vs. 32% and 28% vs. 23%, respectively). Mean LDL-Clevels in the 12-month pre-index period were slightly higher forCHD patients, whereas median triglyceride levels were signifi-cantly higher for patients with diabetes.

The days of supply of lipid-modifying drugs are presented inTable 3. For all patients, the mean days supply represented ap-proximately two-thirds of days in months 1-6 (114 of 180 days)and months 1-12 (224 of 360 days). The mean numbers of dayssupply were greater for patients with CHD than for patients withdiabetes in months 1-6 (126 vs. 101 days) months 1-12 (236 vs.214 days), and overall (542 vs. 466 days).

Of the 11,552 patients in the study population, 4,676(40.5%) had lipid testing data available in months 1-6 (Table1). Of the 4,676 patients tested, 3,400 (72.7%, distributed as63.5% of CHD patients and 76.5% of patients with diabetes)had LDL-C ≥ 100 mg per dL. A total of 1,245 patients weretested and treated with lipid-modifying therapy in months 1-6.Of these 1,245 patients, 485 (39.0%) were at their LDL-C goalin months 1-6 (48.2% of CHD and 28.8% of diabetes patients),and 760 (61.0%) were not at their LDL-C goal (51.8% of thosewith CHD and 71.2% of those with diabetes). Among the 760patients tested and treated and not at goal in months 1-6, 600(79.0%) were treated in months 7-12, of whom 138 (23.0%of 600) attained LDL-C goal, and 496 (65.3% of 760) weretreated after month 12, of whom 241 (31.8%) attained LDL-Cgoal (Figure 3). Cumulative goal attainment for those treatedwas 39.0% in months 1-6, 50.1% in months 7-12, and 58.4% inmonth 7 to the end of the post-index period.

The multivariate analyses showed that among patients who

did not attain LDL-C goal in months 1-6 and who continued tobe treated, there was no significant difference in goalattainment between CHD and diabetes patients in months7-12 or in month 7 to the end of the post-index period (Table 4).The overall predicted probability of attaining LDL-C goal inmonth 7 to the end of the post-index period was 48.8% (95%confidence interval [CI],44.0%-53.6%), with little difference inthe probability of goal attainment for patients with CHD (49.4%,95% CI,42.2%-56.7%) and for those with diabetes (48.2%, 95%CI, 41.4%-55.1%). The odds of goal attainment in month 7 tothe end of the post-index period (among those not at goal inmonths 1-6) were greater for (a) age ≥ 65 years (odds ratio [OR]=2.45, 95% CI,1.62-3.72), (b) history of hypertension (OR=1.91,95% CI, 1.20-3.03), (c) number of distinct medications (OR =1.07, 95% CI,1.01-1.14 per additional medication), (d) monthsof observation post-index (OR=1.04, 95% CI, 1.01-1.08 peradditional month), and (e) months supply of lipid-modifyingmedication (OR=1.04, 95% CI, 1.01-1.07 per additionalmonth), and were lower for LDL-C ≥ 130 mg per dL in months1-6 (OR=0.53, 95% CI, 0.35-0.82) and a history of dyslipid-emia (OR=0.54, 95% CI, 0.35-0.83). The odds of LDL-C goalattainment were not affected by gender, statin titration (34% ofpatients), lipid-modifying drug switching (39% of patients), ortreatment with a high-potency LDL-C-lowering drug dosage (ofsufficient strength to reduce LDL-C by > 40%). Both modelsdemonstrated good fit and discrimination, as measured by theHosmer-Le show goodness-of-fit statistic and area under theROC curve, respectively.

nn DISCUSSIONIn this study, we examined the course of lipid managementand LDL-C goal attainment for an average of 26 months aftera new diagnosis of CHD or diabetes in a managed care setting.Patients who were treated with lipid-modifying drugs but whodid not attain LDL-C goal in months 1-6 had only about a 1 in 2predicted probability (48.8%) of goal attainment in months 7 tothe end of the post-index period, regardless of CHD or diabetesdiagnosis.

There have been few longitudinal studies of rates of lipidtesting, lipid drug treatment, and LDL-C goal attainment amongpatients with diabetes or CHD in the period since publica-tion of the 1994 ATP II and 1998 ADA guidelines, which firstadvocated the LDL-C standard of < 100 mg per dL for CHDand diabetes, respectively.3,4 Beaton et al. reported an LDL-Ctesting rate of 54% and a lipid-lowering drug treatment rate of28% for patients with diabetes in managed care in 1999-2000.8

Reported rates of LDL-C goal attainment (< 100 mg per dL)were 62% for patients with CHD in 200318,24 and 32%-55%for patients with diabetes in 1999-2003.8-10,18 These studieswere all cross-sectional and included national surveys.18,24 TheNational Committee for Quality Assurance has reported rates ofLDL-C testing and goal attainment in participating US managed



TABLE 2 Characteristics of Study Sample of Newly Diagnosed Patients with Coronary Heart Diseaseor Diabetes Mellitus

Characteristics

All

(n = 11,552)

CHD

(n = 3,320)

Diabetes

(n = 8,232) P Value*

Age

Mean years [SD] 61.2 [14.7] 64.4 [14.2] 60.0 [14.7] < 0.001

65 years (%) 45.1 53.4 41.8 < 0.001

Male (%) 52.5 56.7 50.8 < 0.001

Duration of post-index period, months

Mean [SD] 25.8 [7.9] 25.6 [7.9] 25.9 [7.9] 0.077

Range (12.2, 42) (12.2, 42) (12.2, 42)

History of hypertension (%) 33.6 37.6 32.0 < 0.001

History of dyslipidemia (%) 24.5 27.9 23.1 < 0.001

Number distinct prescription medications, mean [SD] 4.4 [3.9] 5.1 [4.1] 4.1 [3.8] < 0.001

Laboratory measurements in 12-month pre-index period

LDL-C

Number of patients 1,520 (45.8%) 3,785 (46.0%)

Mean mg per dL [SD] 130.7 [33.4] 132.6 [33.2] 0.011

Median mg per dL (IQR) 129 (108, 151) 130 (110, 153) 129 (107, 151)

Triglycerides†

Number and % of patients 1,628 (49.0%) 4,182 (20.8%)

Mean mg per dL [SD] 189.1 [209.5] 155.1 [96.3] 202.3 [238.2]

Median mg per dL (IQR) 133 (96, 188) 157 (109, 230) < 0.001149 (104, 219)

5810 (50.3%)

5305 (45.9%)

130.0 [33.5]

*P values determined from independent 2-sample t tests for continuous variables and Pearson chi-square tests for categorical variables; the nonparametric median test wasused for triglycerides.†Triglyceride levels are highly skewed. As a result the mean is not the best measure of central tendency.CHD = Coronary heart disease; IQR = interquartile range; SD = standard deviation.

All

(n = 11,552)

61.2 [14.7]

45.1

52.5

25.8 [7.9]

(12.2, 42)

33.6

24.5

4.4 [3.9]

130.7 [33.4]

129 (108, 151)

189.1 [209.5]

149 (104, 219)

5810 (50.3%)

5305 (45.9%)

>



care plans for diabetes (but not CHD) for 1998-2002 (whenthe HEDIS goal was LDL-C < 130 mg per dL) and 2003-2005(LDL-C goal < 100 mg per dL).25 The HEDIS rate ofLDL-C < 100 mg per dL for diabetes in commercial planswas 35%-44% in 2003-2005.25 The corresponding rate forLDL-C < 130 mg per dL was 29%-55% in 1999-2002 and60%-68% in 2003-2005.25

There have been few longitudinal studies of patients withCHD or diabetes. Retrospective cohort studies have focusedon patients with hyperlipidemia15,26 and patients treated withlipid-modifying drugs,27 or specifically with statins (during1997-2004)28-31 although there have been some retrospec-tive cohort studies of high-risk patient groups (during 1996-2001).16,17,32 Many of these studies focused on adherence todrug therapy.28,29,31,32 Stacy and Egger reported that treatmentwith lipid-modifying drugs increased LDL-C goal attainmentfrom 23% at baseline (prior to any drug treatment) to 68% overan average of 3.7 years later (in 2004).26 These patients hadhyperlipidemia and/or hypercholesterolemia, however,rather than CHD or diabetes, and were treated by high-volume

prescribers, so that most patients (84%) had received at least1 lipid-modifying medication.26 Valuck et al. and Meyer etal. reported that patients treated with high-potency statinregimens were significantly more likely to attain an LDL-C goal< 100 mg per dL than patients treated with non-high-potencyregimens.17,27

In the present study, fewer patients with a new diagnosis ofdiabetes received lipid-modifying medication or attained theLDL-C goal of < 100 mg per dL than did newly diagnosed CHDpatients. There are several reasons why this may haveoccurred. First, diabetes patients may have received less inten-sive LDL-C testing and treatment, because the focus in newlydiagnosed diabetes patients is often on control of blood glucose.Second, since our definition of CHD included conditionslikely to require urgent medical care and/or hospitalization(e.g., myocardial infarction, angioplasty, coronary artery bypassgraft), newly diagnosed CHD patients may have been perceivedas needing more aggressive therapy. Finally, the data for thisstudy were recorded between January 1, 1998 and June 30,2002 and, although the ADA guidelines have recommended an

TABLE 3 Days Supply of Lipid-Modifying Drug Therapy

Variable Total CHD Diabetes P Value*

Months 1 to 6

Number of patients 1245 651 594

Mean days of therapy [SD] 114 [60] 126 [63] 101 [56] < 0.001

Median days of therapy (IQR) 120 (60, 155) 120 (60, 180) 98 (60, 150)

Months 1 to 12


Mean days of therapy [SD] 224 [90] 236 [92] 214 [88] 0.002



Mean days of therapy [SD] 502 [249] 542 [266] 466 [277] < 0.001


IQR = interquartile range; SD = standard deviation. *P values for comparisons of means for Coronary Heart Disease (CHD) and diabetes using independent 2-sample t tests.

Month 1 to end of post-index period



LDL-C goal of < 100 mg per dL for diabetes since 1998, theNCEP ATP II and HEDIS standard was LDL-C < 130 mg per dL.

nn LimitationsForemost among the study limitations is the uncertainty aboutwhich was the prevailing standard for LDL-C goal attain-ment for patients with diabetes during the study period. TheATP II LDL-C goal for CHD was < 100 mg/dL throughout ourstudy period, as was the ADA goal for LDL-C in patients withdiabetes. The formal release of the NCEP ATP III guidelines, whichswept all diabetes patients regardless of CHD status into the newLDL goal of < 100 mg per dL, occurred after our study period,although the executive summary of the new ATP III guidelineappeared in May 2001, in the last year of our post-index period.In addition, the HEDIS standard for diabetes was LDL-C <130mg per dL throughout our study period.25 Therefore, while wemay comment on whether standards for LDL-C goal attainmentamong CHD patients were met, we cannot make a definitivestatement regarding physician adherence to clinical standardsfor lipid management in patients with diabetes. However, a

survey of office-based physicians through 2004 indicated that theappearance of the 1998 ADA and 2001 ATP III guidelines hadlittle impact on trends in LDL-C testing and attainment of the< 100 mg per dL goal.33 Rates of LDL-C testing and goalattainment were trending upwards for both CHD anddiabetes since 1998 and were apparently unaffected by ATP III.33

However, Ye et al. reported recently that the proportion ofpatients who received a statin after a CHD hospitalizationincreased in each of 4 years to an average 56% of patients in2003.34

Second, we defined continuous treatment broadly. Contin-uous treatment could have been as few as 2 pharmacy claims(i.e., 2 months of treatment) for a lipid-modifying drug in thefirst 12 months of follow up although the median was 7 monthsand at least 1 fill was required in each time period.

Third, the temporal relationship between the date of LDL-Ctesting and drug treatment within any given time period was notcaptured. It is possible, for example, that the LDL-C value wasrecorded prior to drug treatment in the first 6-month period(if this was either the only or the lowest LDL-C recording).

FIGURE 3 Lipid Goal Attainment Rates Among Treated Patients*

Total‡ 496 (100%)At goal 241 (49%)Not at goal 255 (51%)

Month 7-end ofpost-index period

Total† 600 (100%)At goal 138 (23%)Not at goal 462 (77%)

Month 7-12

Month 1-6

Total 1,245 (100%)At goal 485 (39%)

Not at goal 760 (61%)

*Goal defined as low-density lipoprotein-cholesterol (LDL-C) < 100 mg per dL.1,2

†600 represents the number of patients treated and not at goal in months 1-6 who were also tested and had 1 or more lipid drug claims in months 7-12.‡496 represents patients treated and not at goal in months 1-6, tested and with 1 or more lipid drug claims in months 7-12, and tested and with 1 or more lipid drug claimsbetween month 13 and the end of the post-index period.



Therefore, our data would tend to underestimate the numberand proportion of patients at target LDL-C goal.

Fourth, lipid values performed in laboratories other thanthe single national provider or tests reported by physicians witha CPT code were not captured. Some patients could also havereceived lipid testing in the hospital, which would have madeoutpatient testing unnecessary for several months. However,due to this limitation, we did not calculate the number andproportion of patients that received LDL-C testing.

Fifth, these results may not be generalizable to other settings.This analysis was limited to 1 MCO located in the southeast-ern United States, and laboratory lipid values within the first

6 months after diagnosis were available for only 40% of thetarget population (4,676 of 11,552 patients), thereby limitingthe sample for which lipid management and goal attainmentcould be assessed.

Sixth, we did not include information on patient race andsocioeconomic status—factors reported previously to affectthe likelihood of LDL-C testing among Medicare patients.35

Last, we did not examine dyslipidemia versus LDL-C, and wecannot be certain that the lipid-lowering drug therapy wasspecifically used to treat elevated LDL-C. Finally, the use of claimsdata prohibited determination of the extent that patients could besplitting tablets. For example, a patient who received 40 mg

TABLE 4 Adjusted Odds Ratios for LDL-C Goal Attainment in Months 7 to 12 and Month 7 to End ofPost-index Period, for Those Who Were Treated and Were Not at LDL-C Goal inMonths 1-6, and Who Continued to be Treated

CharacteristicMonths 7 to12

(N = 598)*Month 7 to End of Post-index Period

(N = 494)†

OR 95% CI OR 95% CI

CHD (vs. diabetes) 1.04 0.68 1.60 0.97 0.63 1.49

Male sex 1.64 1.05 2.57 1.29 0.83 1.99

Age 65 years 2.06 1.34 3.15 2.45 1.62 3.72

LDL-C 130 mg per dL in months 1-6 0.70 0.45 1.08 0.53 0.35 0.82

HDL-C 40 mg per dL in months 1-6 0.90 0.55 1.49 0.81 0.49 1.33

TC 200 mg per dL in months 1-6 0.92 0.57 1.48 1.06 0.66 1.70

History of hypertension 1.47 0.94 2.31 1.91 1.20 3.03

History of dyslipidemia 0.81 0.53 1.23 0.54 0.35 0.83

Number distinct medications 1.10 1.04 1.16 1.07 1.01 1.14

Months of observation ---- 1.04 1.01 1.08

Statin titration‡ 0.77 0.45 1.32 0.75 0.46 1.22

Switching§ 1.21 0.74 1.99 0.94 0.60 1.47

High-potency LDL-C-lowering dosage 1.04 0.61 1.76 1.27 0.79 2.04

Months supply¶ 1.02 0.95 1.10 1.04 1.01 1.07

*Hosmer-Lemeshow goodness-of-fit chi-square (df = 8) = 3.90, P = 0.866; area under receiver operating characteristic (ROC) curve = 0.679. Two patients were excludeddue to lack of HDL-C measurement in months 1-6.†Hosmer-Lemeshow goodness-of-fit chi-square (df = 8) = 4.44, P = 0.815; area under ROC curve = 0.730. Two patients were excluded due to lack of HDL-C measurementin months 1-6.‡Defined as an increase in the strength of the dispensed statin. Totals for 136 patients (22.7%) were titrated in months 1-12, and 167 patients (33.7%) were titrated inmonths 1 to the end of post-index period.§Defined as a claim for any lipid drug (statin or nonstatin) different from the previous lipid drug fill, with no subsequent claim for the original drug. Totals for 142 patients(23.7%) were titrated in months 1-12, and 192 patients (38.7%) were titrated in months 1 to the end of post-index period.¶Observed for patients with statin use, imputed for nonstatin users.

>

CHD = coronary heart disease; OR = odds ratio; CI = confidence interval; LDL-C = low-density lipoprotein-cholesterol; HDL-C = high-density lipoprotein-cholesterol;TC = total cholesterol.

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simvastatin tablets could have actually taken 20 mg per day bysplitting the tablets. However, the days supply in most caseswould have been adjusted accordingly (i.e., a 60-day supply for30 units of 40 mg simvastatin at a 20 mg dose per day).

CONCLUSIONOnly 27% of patients with CHD or diabetes patients whoreceived a lipid test were at the LDL-C goal of < 100 mg perdL in the first 6 months after diagnosis. Among those who alsoreceived lipid-modifying drug therapy, only 39% were at goal inthe first 6 months. The probability of goal attainment increasedover the follow-up period, but for those who did not reachLDL-C goal in the first 6 months after diagnosis, goal attain-ment remained below 50% over the entire post-index period,averaging 26 months.

ACKNOWLEDGMENTSThe authors acknowledge the contribution of Alan Morrison, PhD, as a medicalwriter.

DISCLOSURES

Funding for this study was provided by Merck-Schering Plough, Inc. AuthorsSoma S. Nag, Shiva G. Sajjan, Sachin Kamal-Bahl, Henry Hu, and CharlesAlexander are employed by Merck & Co., Inc., West Point, PA. Alexander,Nag, Sajjan, Hu, and Kamal-Bahl are shareholders of Merck & Co. Gregory W.Daniel discloses no potential bias or conflict of interest relating to this study.Michael F. Bullano discloses no potential bias or conflict of interest relating tothis study.

Nag served as principal author of the study. Study concept and design werecontributed by Nag, Hu, Daniel, Alexander, and Bullano. Data collection wasthe work of Daniel and Bullano with input from Nag; data interpretation wasprimarily the work of Nag and Sajjan with input from Hu, Daniel, andAlexander. Writing of the manuscript and its revision was primarily the workof Nag, Kamal-Bahl, and Alexander with input from Hu, Daniel, and Bullano.

REFERENCES

1. National Institute of Health, National Heart Lung and Blood Institute,National Cholesterol Education Program. Third Report of the NationalCholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)Executive Summary 2001. NIH Publication No. 01-3670.

2. American Diabetes Association. Dyslipidemia management in adults withdiabetes. Diabetes Care. 2005;28:S4-36.

3. Summary of the second report of the National Cholesterol EducationProgram (NCEP) Expert Panel on Detection, Evaluation, and Treatment

of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA.1993;269(23):3015-23.

4. Management of dyslipidemia in adults with diabetes. American Diabetes As-sociation. Diabetes Care. 1998;21(1):179-82.

5. Kell SH, Drass J, Bausell RB, Thomas KA, Osborn MA, Gohdes D. Measuresof disease control in Medicare beneficiaries with diabetes mellitus. J Am GeriatrSoc. 1999;47(4):417-22.

6. Harris MI. Health care and health status and outcomes for patients with type2 diabetes. Diabetes Care. 2000;23(6):754-58.

7. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, NarayanKM. A diabetes report card for the United States: quality of care in the 1990s.Ann Intern Med. 2002;136(8):565-74.

8. Beaton SJ, Nag SS, Gunter MJ, Gleeson JM, Sajjan SS, Alexander CM.Adequacy of glycemic, lipid, and blood pressure management for patients withdiabetes in a managed care setting. Diabetes Care. 2004;27(3):694-98.

9. Putzer G, Roetzheim R, Ramirez AM, Sneed K, Brownlee HJ, Jr., CampbellRJ. Compliance with recommendations for lipid management among patientswith type 2 diabetes in an academic family practice. J Am Board Fam Pract.2004;17(2):101-07.

10. Parris ES, Lawrence DB, Mohn LA, Long LB. Adherence to statin therapyand LDL cholesterol goal attainment by patients with diabetes and dyslipidemia.Diabetes Care. 2005;28(3):595-99.

11. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree ofundertreatment of hyperlipidemia and congestive heart failure secondary tocoronary artery disease. Am J Cardiol. 1999;83(9):1303-07.

12. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessmentproject (L-TAP): a multicenter survey to evaluate the percentages of dyslip-idemic patients receiving lipid-lowering therapy and achieving low-densitylipoprotein cholesterol goals. Arch Intern Med. 2000;160(4):459-67.

13. Straka RJ, Taheri R, Cooper SL, Tan AW, Smith AC. Assessment ofhypercholesterolemia control in a managed care organization. Pharmacother.2001;21(7):818-27.

14. Latts LM. Assessing the results: phase 1 hyperlipidemia outcomes in 27health plans. Am J Med. 2001;110(S 6A):17S-23S.

15. Dubois RW, Alexander CM, Wade S, et al. Growth in use of lipid-lowering therapies: are we targeting the right patients? Am J Manag Care.2002;8(10):862-67.

16. Nag SS, Pearson TA, Ma L, et al. Estimating cholesterol treatment ratesamong individuals with multiple risk factors and without coronary heartdisease. Am J Cardiol. 2005;95(7):862-64.

17. Meyer JW, Schultz JS, O’Donnell JC, Patel PA, Sasane RM. Patternsand effectiveness of lipid-lowering therapies in a managed care environment.Value Health. 2005;8(5):601-12.

18. Davidson MH, Maki KC, Pearson TA, et al. Results of the National Choles-terol Education (NCEP) Program Evaluation ProjecT Utilizing Novel E-Tech-nology (NEPTUNE) II survey and implications for treatment under the recentNCEP Writing Group recommendations. Am J Cardiol. 2005;96(4):556-63.

19. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentrationof low-density lipoprotein cholesterol in plasma, without use of the preparativeultracentrifuge. Clin Chem. 1972;18(6):499-502.

20. Schneeweiss S, Seeger JD, Maclure M, Wang PS, Avorn J, Glynn RJ. Per-formance of comorbidity scores to control for confounding in epidemiologicstudies using claims data. Am J Epidemiol. 2001;154(9):854-64.

21. Farley JF, Harley CR, Devine JW. A comparison of comorbidity measure-ments to predict healthcare expenditures. Am J Manag Care. 2006;12(2):110-19.

22. Hosmer DW, Lemeshow S. Applied logistic regression 2nd ed. New York: JohnWiley & Sons; 2000.

SoMA S. NAG, PhD, is associate director, Merck & Co., Inc., West Point, PA;GREGoRy W. DANIEl, RPh, MS, MPH, is research operations director, HealthCore, Inc., Wilmington, DE; MICHAEl F. BullANo, PharmD, is associatedirector, Health Economics and outcomes Research, Astra-Zeneca lP,Wilmington, DE; SACHIN KAMAl-BAHl, PhD, is associate director, Merck& Co., Inc., West Point, PA; SHIVA G. SAJJAN, PhD, is senior manager, Merck &Co., Inc., West Point, PA; X. HENRy Hu, MD, PhD is senior director, Merck &Co., Inc., West Point, PA; CHARlES AlEXANDER, MD, is senior director, Globaloutcomes Research, Merck & Co., Inc, West Point, PA.

AUTHOR CORRESPONDENCE: Dr. Soma S. Nag, 770 Broad Streetand Sumneytown Pike, WP39-166 19486, Tel.: (215) 652-9219;Fax: (215) 652-0860; E-mail: [email protected].

Authors



23. Buis M. Predict and adjust with logistic regression. The Stata J. 2007;7(2):221-26.

24. Ansell BJ, Fonarow GC, Maki KC, Dicklin MR, Bell M, Davidson MH.Reduced treatment success in lipid management among women with coronaryheart disease or risk equivalents: results of a national survey. Am Heart J.2006;152(5):976-81.

25. National Committee for Quality Assurance The State of Health Care Quality2006. Washington, DC: National Committee for Quality Assurance; 2006.

26. Stacy TA, Egger A. Results of retrospective chart review to determineimprovement in lipid goal attainment in patients treated by high-volumeprescribers of lipid-modifying drugs. J Manag Care Pharm. 2006;12(9):745-51.Available at: http://www.amcp.org/data/jmcp/745-51.pdf.

27. Valuck RJ, Williams SA, MacArthur M, et al. A retrospective cohort study ofcorrelates of response to pharmacologic therapy for hyperlipidemia in membersof a managed care organization. Clin Ther. 2003;25(11):2936-57.

28. Schultz JS, O’Donnell JC, McDonough KL, Sasane R, Meyer J. Determinantsof compliance with statin therapy and low-density lipoprotein cholesterol goalattainment in a managed care population. Am J Manag Care. 2005;11(5):306-12.

29. Kopjar B, Sales AE, Pineros SL, Sun H, Li YF, Hedeen AN. Adherence withstatin therapy in secondary prevention of coronary heart disease in veteransadministration male population. Am J Cardiol. 2003;92(9):1106-08.

30. Quilliam BJ, Perez HE, Andros V, Jones P. Quantifying the effect of applyingthe NCEP ATP III criteria in a managed care population treated with statintherapy. J Manag Care Pharm. 2004;10(3):244-50. Available at: http://www.amcp.org/data/jmcp/Research-244-250.pdf.

31. Thiebaud P, Patel BV, Nichol MB, Berenbeim DM. The effect of switchingon compliance and persistence: the case of statin treatment. Am J Manag Care.2005;11(11):670-74.

32. Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adher-ence with antihypertensive and lipid-lowering therapy. Arch Intern Med.2005;165(10):1147-52.

33. Wang YR, Alexander GC, Meltzer DO. Lack of effect of guideline changeson LDL cholesterol reporting and control for diabetes visits in the U.S., 1995-2004. Diabetes Care. 2005;28(12):2942-44.

34. Ye X, Gross CR, Schommer J, Cline R, Xuan J, St Peter WL. Initiation ofstatins after hospitalization for coronary heart disease. J Manag Care Pharm.2007;13(5):385-96. Available at http://www.amcp.org/jmcp/JMCPMaga_June07_p385-396.pdf.

35. Massing MW, Henley NS, Carter-Edwards L, Schenck AP, Simpson RJ, Jr.Lipid testing among patients with diabetes who receive diabetes care fromprimary care physicians. Diabetes Care. 2003;26(5):1369-73.


ReseaRch

Outpatient prescription drug spending in the UnitedStates was $200.7 billion in 2005 with a 5.8% increaseover 2004.1 To control rising prescription drug costs,

managed care organizations (MCOs) and the employers withwhom they contract began utilizing multitiered formularies afterthe early 1990s.2 To offset the continued increase in prescriptiondrug spending, many health plans have increased prescriptioncost-sharing across all copayment tiers.2 In 2006, the mostcommon commercial pharmacy benefit design employed3-tier copayments with average member cost-share of $11 for

BACKGROUND: Effective treatment for chronic diseases often requiresmedication refill persistence. Health plans have frequently increased theamount of member cost-sharing by implementing tier-copayment pharmacybenefit designs and raising copayments. However, increased member cost-share may present a barrier to the management of chronic conditions. Littleis known about the relationship between the magnitude of member cost-shar-ing and antihypertensive persistence among members newly initiating therapy.

OBJECTIVE: To investigate and quantify the relationship between amount ofprescription cost-sharing and medication refill persistence among membersnewly initiating therapy with a single-agent angiotensin system blocker—either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin IIreceptor blocker (ARB).

METHODS: This was an observational cohort study of pharmacy and medicalclaims data for 29 employers with approximately 310,000 beneficiaries thatdid not have a change in pharmacy benefits including the amount of membercost-share in 2004. The claims data were supplemented with census data forhousehold income and race at the Zip Code level. Selected patients were newusers of single-agent ACEIs or ARBs (i.e., excluding ACEI or ARB in combina-tion with hydrochlorothiazide or amlopdipine) between January 1 and June30, 2004, without a pharmacy claim for an ACEI or an ARB in the 6 monthsprior to the index claim for either drug type. Medication refill persistence wasmeasured in 3 ways: (1) total number of days without ACEIs or ARBs during6 months follow-up, (2) proportion of days covered (PDC) with less than 80%defined as nonpersistent during 6 months follow-up, and (3) number of daysto the first gap of more than 30 days in medication coverage from the indexdate to end of 2004 (mean [SD] follow-up=9.2 [1.8] months). Three statisticalmodels were fit: Tobit model, examining the association between cost-shar-ing and total number of medication gap days; logistic regression, testing theassociation between cost-sharing and odds of being nonpersistent; and Coxproportional hazards model, assessing the association between cost-sharingand time to a 30-day gap.

RESULTS: Among the eligible population, a study cohort of 1,351 membersnewly initiating a single-agent ACEI or ARB was identified. These memberswere 41.8% female and had a mean age of 55.9 (SD=13.1) years. On average,their member cost-share was $12.42 (SD=$8.50) per 30-day supply. Each$1 increment in per 30-day cost-share was associated with a 1.9% increasein total gap (β=0.019, 95% confidence interval [CI], 0.007-0.030, P=0.001), a2.8% increase in the odds of being nonpersistent (odds ratio [OR]=1.028, 95%CI,1.011-1.045, P=0.001), and a 1.0% increase in the risk of having a gap ofmore than 30 days (hazard ratio [HR]=1.010, 95% CI, 1.001-1.019, P=0.034).Following transformation of the cost-sharing coefficient in each model, a $10increment in cost-share had a consistent negative influence; 18.9% greatertotal gap days (β=0.189, 95% CI, 0.073-0.304), 31.9% greater odds of beingnonpersistent (OR=1.319, 95% CI, 1.120-1.553), and 10.2% larger hazard ofhaving a gap of more than 30 days (HR=1.102, 95% CI, 1.007-1.205).

CONCLUSION: For members newly initiating single-agent angiotensin systemblocking medication, the amount of prescription cost-sharing was associatedwith a negative impact on refill persistence.

Relationship of the Magnitude of Member Cost-Share and MedicationPersistence With Newly Initiated Renin Angiotensin System Blockers

Dongmu Zhang, PhD; angeline M. carlson, PhD; Patrick P. Gleason, PharmD;stephen W. schondelmeyer, PhD; Jon c. schommer, PhD; Bryan e. Dowd, PhD;

and alan h. heaton, PharmD

ReseaRch

Keywords: ACEI inhibitors, ARBs, Cost-sharing, Hypertension, Persistence



• Among members newly initiating angiotensin system blockingmedication, each $1 increment in member cost-share for theinitial prescription claim was associated with 2.8% greaterodds of being nonpersistent at 6 months after initiating therapy.

• Among members newly initiating angiotensin system blockingmedication, each $1 in member cost-share for the initialprescription claim was associated with a 1.9% increase in totalmedication gap in therapy.

• The magnitude of member cost-share was found to have aconsistent effect on medication persistence by 3 measures: totalgap, odds of being nonpersistent, and risk for a 30 day gap.

• In a quasi-experimental (pre-post with comparison group)study, rates of persistency with antihypertensive therapy werenot significantly affected by the implementation of a cost-shareincrease of $13 per prescription for 29% of antihypertensiveuse and $1 to $3 for the remaining 71% of antihypertensive use.

• When comparing antihypertensive persistence among 3 benefittiers (generics, preferred brands, and nonpreferredbrands), using the measure of proportion of days covered,researchers have found an inverse association between cost-share and persistence.

• The quantitative relationship between antihypertensive cost-sharing and persistence among members newly initiatingtherapy is unknown.

aBsTRacT



Relationship of the Magnitude of Member Cost-Share andMedication Persistence with Newly Initiated Renin Angiotensin System Blockers

generic drugs, $24 for preferred brand-name drugs, and $38 fornonpreferred brand-name drugs.3

One rationale behind prescription cost-sharing is to makeconsumers sensitive to prescription costs so that they will limit“nonessential” use and utilize generic or less expensive brandeddrugs when needed. In a recent literature summary of 65studies, researchers examined prescription drug cost-sharingassociations with medication and medical utilization andspending.4 Using an unspecified meta-analytic calculationmethodology, the authors found that for each 10% increase incost-sharing, prescription drug spending decreased by 2% to6%, dependent upon the drug class and the patient conditions.In a statistical model derived from a cross-sectional analysis ofclaims data from 25 employers, it was estimated that doubling amember’s copayment was associated with a 22% to 35%reduction in average annual prescription drug spending permember, with a proportional reduction in utilization.5 Otherwell-designed studies assessing pharmaceutical utilization andspending associated with changes to the pharmacy benefitdesign, as defined by Goldman et al., demonstrated similartrends in decreased utilization and costs associated withincreased cost-share.6-23 However, in several of the betterdesigned (e.g., pre-post with comparison group) studies evalu-ating the effect of benefit design changes, which result in highercost-share to some members, researchers found much smallerdecreases in utilization than observed in the cross-sectionalstudies. These authors also found significant shifts from nonpre-ferred products to preferred products, one of the desiredoutcomes of multitier pharmacy benefit designs.14-15,20-22 Apre-post comparison of utilization of diabetes medicationsuggested that a greater than $10 increase in cost-share isnecessary to induce a significant decrease in utilization.11

An unintended consequence of large increases in cost-sharingwith subsequent large reductions in prescription drug spendingmay be that members forgo “essential” medication use, raisingconcern about adverse health outcomes, particularly for individ-uals with chronic illness.9 In a well-designed pre-post withcomparison group study, the authors found no significant differ-ences in medical utilization, including inpatient hospitaladmissions, emergency room visits, and office visits, followingimplementation of a copayment increase.21-22 That study alsofound that rates of persistency with antihypertensive andantilipidemic therapy were not significantly affected by thecopayment change. The minimal association between medicaloutcomes and pharmacy cost-share in that study may in part bedue to the small increases in cost-sharing most members experi-enced; cost-sharing went from a 2-tier structure of $7 and $12 toa 3-tier of $8, $15, and $25. Based on pre-implementation claims,only 14% of overall utilization, 29% of antihypertensive utiliza-tion, and 11% of antilipidemic utilization were subject to thelargest increase in cost-share from $12 to $25. All other mem-bers’ cost-sharing went from either $7 to $8 or from $12 to $15.

In addition, an assessment of a Canadian provincial healthsystem change in prescription coverage from $2 copayment perprescription to 25% coinsurance with income-based out-of-pocket annual maximums showed no dramatic differences inpersistence or in cardiovascular outcomes in a pre-post design.24

This Canadian study is limited because it is not possible to quan-tify the individual difference in cost-share per prescription, andthe U.S. health system lacks a comparable type of benefit designwith income-based annual out-of-pocket maximum cost-share.

It is important to develop an understanding of the incremen-tal effect that member cost-sharing has on “essential” medicationpersistence, especially for members newly initiating medicationtherapy. Among cardiovascular medications shown to reducemedical events, such as antihypertensives and lipid-loweringtherapy, a handful of researchers have examined the associationbetween prescription cost-sharing and medication persistence,but without consistent results.6-9,14,17,20,23-27 These studies haveconsisted of a mix of users newly initiating and those currentlyon therapy. Another limitation of these studies is inconsistencyin the definition of persistence and persistence measurementmethodology.28 Therefore, it is difficult to make comparisonsbetween studies.

Persistence is generally measured in 3 ways, as a function of:(1) medication possession ratio (MPR) or proportion of dayscovered (PDC); (2) medication availability at a fixed time point;or (3) gaps in medication coverage.29 Even though quasi-experi-mental study design (pre-post with comparison group) has goodinternal validity, it can only examine whether there is an impactof prescription cost-sharing on persistence based on the magni-tude of cost-sharing change. The fixed cost-sharing in pre-postcomparison studies does not allow assessment of a continuousquantitative relationship between cost-share and persistence.Furthermore, in pre-post comparison studies, not only theeffects of prescription cost-sharing, but also the responsestoward a pharmacy benefits change, are measured. In mostcross-sectional studies, cost-sharing is either assessed by a priceindex or approximated by formulary tiers, neither of whichmeasures members’ actual economic burden. To our knowledge,at the time of this research, no one had investigated membersnewly initiated on therapy and the associated proportional effectof prescription cost-sharing on the level of nonpersistence.Finally, the main purpose of most of the published studies wasto quantify the impact of a change in cost-sharing on prescrip-tion drug utilization, expenditure, and persistence.8-9,14,17,20,24

To our knowledge, the studies of cardiovascular drugs inwhich authors have attempted to quantify mathematically therelationship between cost-share and persistence were in thestatin drug class 6,7,25 or focused on congestive heart failurepatients.23 Two antihypertensive studies evaluating the relation-ship between persistence and member cost-share focused ondifferences in persistence between 3 copayment tiers using thePDC metric.26,27 Both of the antihypertensive studies found that



higher cost-share was a significant independent negative predic-tor of persistence. However, the studies are limited due to theuse of 1 persistence measure and the inability to quantify therelationship between the amount of cost-share and persistence.

The objective in this study was to investigate and quan-tify the influence of the amount of prescription cost-share onmedication refill persistence among members newly initiatingangiotensin system-blockers: angiotensin converting enzymeinhibitors (ACEIs) or angiotensin II receptor blockers (ARBs).ACEIs and ARBs are primarily prescribed for hypertension30

and have been associated with higher persistence rates thanother antihypertensive therapeutic classes.31-33 They have asimilar mechanism of action, reducing the effect of angio-tensin II on the body, and nearly identical side effect profileswith a higher proportion of patients reporting cough withACEIs.34-35 The equivalent effectiveness and safety of ACEIs andARBshasbeen recently reported in theAgency forHealthResearchand Quality document “Comparative effectiveness of angioten-sin-converting enzyme inhibitors (ACEIs) and angiotensin IIreceptor antagonists (ARBs) for treating hypertension.”35

During the present study, 6 single-agent ACEIs wereavailable by generic name (captopril, enalapril, fosinopril,lisinopril, moexipril, and benazepril), 4 single-agent ACEIs wereavailable as brand only (trandolapril, perindopril, quinapril, andramipril), and all single-agent ARBs were available as brand only.This distribution of study drugs across copayment tierspermits analysis of the relationship between cost-share amountand persistence.

nn METHODSThis observational cohort study used a Midwest commercialinsurer’s medical and pharmacy administrative claims data forhealth benefit services provided to 1.7 million members. To beeligible for analysis, members were required to have beencontinuously enrolled from July 1, 2003 to December 31, 2004with a health plan group, pharmacy benefit, and cost-share thatdid not change during 2004. There were 29 employers that metthese criteria, representing approximately 10% of the totalmembership of this commercial insurer. From these 29employers, we identified new users of single angiotensin system-blocking (ACEI or ARB) agents. Combination products wereexcluded because the single angiotensin system-blocking agentsare associated with significantly higher persistence rates thanother antihypertensive drug classes.36 By limiting the analysis tosingle-agent angiotensin system blockers, we reduce thepotential for agents such as hydrochlorothiazide in combinationproducts to negatively influence persistence. A new user wasdefined as an individual who started treatment with ACEI(Medi-Span’s 6-digit Generic Product Identifier [GPI] code361000) or ARB (code 361500) single agents (excluding ACEI/calcium channel blockers, ACEI/hydrochlorothiazide, and ARB/hydrochlorothiazide combinations) between January 1, 2004

and June 30, 2004 with no ACEI or ARB single agents orcombinations dispensed in the 6 months (180 days) precedingthe index date.

The first pharmacy claim for an ACEI or ARB single agentwas defined as the index event, and the date of the index phar-macy claim was defined as the index date. The new users hadto meet several inclusion criteria: (1) 18 years of age or older onthe index date, (2) at least 28 days supply in the index pharma-cy claim, (3) no facility hospitalization or long-term care claimof any duration after the index date, and (4) no diagnosis ofdementia (ICD-9-CM codes 290.xx, 294.1x, 331.0x, 331.1x or331.2x). Members were followed for 2 periods: from the indexdate to 6 months after the index date and from the index date tothe end of 2004.

VariablesMedication refill persistence was measured 3 ways based ondays supply recorded in pharmacy claims to quantify theintensity and duration:28,29 (1) total gap or total number ofdays without medication during the first 6 months of treat-ment, (2) proportion of days covered (PDC) with less than 80%defined as nonpersistent (less than 144 days of coverage) duringthe first 6 months of treatment, and (3) time to a gap of more than30 days in medication coverage from the index date to the endof 2004. Days supply that overlapped with previous pharmacyclaims or extended past the observation period were not used incalculating persistence. Switching to a single-agent ARB or ACEIwas counted as a continuation of treatment as long as the othercriteria for continuation (e.g., no more than a 30-day gap) weremet. However, members switching to a combination product orto an antihypertensive product in a different therapy class (e.g.,beta blockers, calcium channel blockers) were defined as havingterminated therapy on the date that the switch claim was filled.Members’ out-of-pocket payment for the index prescription asrecorded in pharmacy claims was used to measure cost-sharingafter adjusting to a 30 days supply (cost-sharing for the initialclaim was divided by days supply to yield cost-sharing per day,then multiplied by 30).

Control variables were selected according to Andersen’sbehavioral model of health services use37 and previous empiricalstudies.6-7,23,25,31-33,36,38-41 Andersen’s model was originally devel-oped in the late 1960s to explain how and why families usehealth services. This model has since been adapted to predictand explain prescription drug use.42-44 According to the model,use of health services, including prescription drugs, is a func-tion of patients’ predisposing characteristics, enabling resources,and need factors. In this study, predisposing characteristics arethose variables that describe the predisposition of individuals tocontinuously use an angiotensin system blocker; enablingresourcesdescribetheabilityofpatientstocontinuouslyobtainanduse an angiotensin system blocker; and need factors describe theprofessionally determined requirements for continuous use of



an angiotensin system blocker.Predisposing characteristics included age, gender, race,

and whether a member previously used any antihypertensivemedications other than ACEIs and ARBs. Because race is notavailable in claims data, it was controlled on an aggregate levelusing percentage of people who reported their race as white onlyin a member’s Zip Code area based on the Census 2000 data.45

Other antihypertensives included diuretics (General ProductIndentifier Code beginning 37), beta-blockers (33), calciumchannel blockers (34), antiadrenergic antihypertensives (3620),aldosterone receptor blockers (3625), direct vasodilators(364000), and antihypertensive combinations (3699) withoutACEIs and ARBs.

Enabling resources included residence (urban, rural, or su-per rural); income; number of unique medications in prior 6months; number of doctor visits from July 1, 2003 to the end of2004; initial therapeutic class (ACEIs or ARBs); utilization ofmail-order service at any time during follow-up; presence of ayearly out-of-pocket maximum in member’s pharmacy benefits;and whether a member used any antidepressant medications:mirtazapine (GPI code 580300), trazodone (58120080),monoamine oxidase inhibitors (581000), selective serotoninreuptake inhibitors (SSRIs, 581600), serotonin norepinephrinereuptake inhibitors (SNRIs, 581800), tricyclic agents (582000),and miscellaneous antidepressants (583000) in the prior 6months. Tricyclic agents were not coded as antidepressantmedications in those members with a diagnosis of diabetes asthese drugs are often used for diabetic neuropathy.

Zip Codes were used to classify members as living in anurban, rural, or super rural area according to the Medicareambulance fee schedule of the Center for Medicare andMedicaid Services (CMS).46 A rural area is defined as an areaoutside a Metropolitan Statistical Area (MSA) or a New EnglandCounty Metropolitan Area, or an area within an MSA identifiedas rural using the Goldsmith modification.47 A super rural area isdefined as a rural area determined by the Secretary of Housingand Urban Development to be in the lowest 25thpercentile of allrural population arrayed by population density.48 An area that isnot classified as a rural or super rural area is considered an urbanarea. Income was also controlled on an aggregate level usinghousehold median income in a member’s Zip Code area basedon the Census 2000 Data.45

Need factors controlled for included conditions that angio-tensin system blocking medications are generally used to treator conditions associated with treatment. These conditions werebased on the International Classification of Diseases, Ninth Revision,Clinical Modification (ICD-9-CM) diagnosis and procedure codesrecorded in medical claims between July 1, 2003 and Decem-ber 31, 2004. Diagnoses included essential hypertension (ICD-9-CM 401.xx), myocardial infarction (410.xx, 411.0x, 412.xx, 414.8x, 429.7x), congestive heart failure (398.91, 402.01,402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91,

404.93, 425.4x, 428.xx), cerebrovascular diseases (362.34,430.xx-438.xx, 784.3x, 997.02, 38.12 (P), 38.42(P), diabetes(250.xx), and dyslipidemia (272.xx).

Statistical AnalysisStatistical analyses were conducted using SAS 9.1 (SAS InstituteInc., Cary, NC). Results were considered statistically significantat P<0.05 (2-tailed). Descriptive statistics, numbers, andpercentages for categorical variables and means and standarddeviations for continuous variables were calculated. Thesedescriptive results were also stratified by cost-sharing tertiles.Cost-sharing tertiles were constructed according to the frequencydistribution of cost-sharing, with each containing aboutone third of the study members. Comparisons of controlvariables across cost-sharing tertiles were conducted withchi-square tests for categorical variables and analyses of variance(ANOVA) for continuous variables. Three statistical modelscorresponding to the 3 measures of medication refill persistencewere performed: Tobit model (proc lifereg), logistic regression(proc logistic) and Cox proportional hazards model (procphreg). All of these models adjusted for the same set of controlvariables.

The Tobit model was used to model the association betweencost-sharing and total gap over the first 6 months of treatment.This approach is appropriate for a dependent variable with adistribution that is spread out over a large range of positivevalues but with a large proportion of observations at the valuezero. In this study, total gap has such a distribution. Although alinear model could capture the expected value of such adependent variable, a linear model will likely lead to negativepredictions for some subjects. In the Tobit model, a naturallogarithmic transformation of total gap is used to address theskewness in the distribution of total gap. Because the naturallogarithm of zero is not defined, every patient’s total gap isadded by one. Normal distribution after log transformation is acritical assumption under the Tobit model. This assumption wasexamined using histogram of residuals (i.e., predicted total gapminus actual total gap). In this study, the histogram of residualsshows that the normal distribution assumption under the Tobitmodel is met (data not shown).

Logistic regression, which is appropriate for describing therelationship between a categorical dependent variable and aset of predictors, was used to examine the association betweencost-sharing and being nonpersistent (PDC < 80%) during thefirst 6 months of treatment. The overall fit of the logistic modelwas assessed using the Hosmer-Lemeshow test. This test dividessubjects into deciles based on predicted probabilities, thencomputes a chi-square from observed and expected frequen-cies. When the test is not significant (P value ≥0.05), the nullhypothesis that the model fits the data well cannot be rejected.The logistic regression model in this study has a Hosmer-Lem-eshow goodness-of-fit test P value of 0.10 suggesting that the



model fits the data (χ2[8] = 13.27).Cox proportional hazards model with the Breslow method

for ties was used to test the association between cost-sharing andtime to a gap of more than 30 days from the index date to theend of 2004. The Cox proportional hazards model assesses theeffects of different covariates on logarithm of rate (log[rate]),without assuming a constant rate over time. A crucial assump-tion of the Cox proportional hazards model is proportionalhazards (i.e., the hazard of having an event at any given time foran individual in one group is proportional to the hazard at thattime for a similar individual in the other group.) Thisassumption was examined by plotting the log-cumulativehazard functions against the log(t). For this study, the plot oflog-cumulative hazard functions against the log(t) suggests thatthe proportional hazards assumption was satisfied (data notshown). Survival curves stratified by cost-sharing tertiles wereshown after adjusting for all the control variables in the Coxproportional hazards model.

Patient PrivacyA limited data set was received after direct individual identifierswere removed to meet the requirements of the Health InsurancePortability and Accountability Act (HIPAA). Year of birth and ZipCodes are allowed in limited data sets. This study was approvedby the University of Minnesota’s Institutional Review Board.

nn RESULTSThere were 175,374 members who were continuously enrolledfrom July 1, 2003 to December 31, 2004 with a health plangroup, pharmacy benefit, and cost-share that did not changeduring 2004. A total of 1,610 new users of an angiotensinsystem-blocking single agent were found between January 1,2004 and June 30, 2004. Two hundred and fifty-seven memberswere excluded due to the inclusion criteria (see Figure 1). Twoadditional members were excluded because they filled both anACEI and an ARB single agent on the same index date. The finalstudy cohort included 1,351 members.

Table 1 shows the members’ pharmacy benefits designs. Amajority of the members had a multitier formulary with 52.9%in a 2-tier copayment structure and 42.6% in a 3-tier structure.The use of a coinsurance-only pharmacy-benefits design wasrare (0.4% of members) in this study cohort.

As shown in Table 2, the cohort was 41.8% female, with amean age of 55.9 (SD=13.1) years (range=18-97). On average,study members initially paid $12.42 (SD=$8.50) for a 30 dayssupply of an angiotensin system-blocking agent. Extrapolationsfrom the Zip Code census data indicate that the study memberslived in relatively wealthy areas (mean of household medianincomes for the Zip Code=$46,366 [SD=$14,449]) with themajority of residents being white (mean percentage of whitepeople in the Zip Code=89.4% [SD=13.2%]). Characteristics ofthe study members were comparable across cost-sharing tertiles

FIGURE 1 Algorithm to Select the Sample ofAngiotensin-Converting Enzyme Inhibitor(ACEI) or Angiotensin II Receptor Blocker(ARB) New Users

Membership file: n=1.7 million

Had group, benefit, or cost-sharingchange in 2004: n=1.4 million

No group, benefit, or cost-sharing changes in2004: n=309,604

Not continuously enrolled July 1, 2003-December 31, 2004: n=134,230

Continuous enrollment July 1, 2003-December 31, 2004: n=175,374

No ACEI or ARB January 1, 2004-June 30, 2004: n=163,342

At least 1 ACEI or ARB claim January 1, 2004-June 30, 2004: n=12,032

Had ACEI or ARB in prior 180 days:n=10,422

No ACEI or ARB in prior 180 days: n=1,610

Age<18: n=9

Age 18: n=1,601

Initial days supply<28: n=33

Initial days supply 28: n=1,568

Nursing home or hospitalization:n=205

No nursing home/hospitalization: n=1,363

Diagnosis of dementia: n=10

No diagnosis of dementia: n=1,353

Both ACEI and ARB on the same indexdate: n=2

Final sample: n=1,351

>

>



(Table 2). Members who paid the highest cost-sharing amountfor their initial claim were more likely to start with ARBs thanmembers who paid lower cost-sharing amounts. This is expectedbecause all ARBs were brand drugs and had higher cost-sharethan ACEIs, which were mostly available as generics. In addi-tion, members who were in the third cost-sharing tertile (highestcost-sharing amount) lived in a Zip Code with lower householdmedian income, had fewer doctor visits, and were less likely tohave a yearly out-of-pocket maximum in their pharmacybenefits design compared with the members in the other 2tertiles. The second cost-sharing tertile had significantly fewermembers who used mail-order pharmacies and more memberswho had a diagnosis of essential hypertension compared with

the first and third tertiles. These differences were adjusted in ourmultivariate analyses.

During the first 6 months of treatment, the study members,on average, had 53 (SD=52) days (range=0-152) without anangiotensin system blocking agent. During the first 6 months,8% of these members had no gap and 47% were classified asbeing nonpersistent (PDC < 80%). From the index date to theend of 2004, 54% of these members had a gap of more than 30days with an average time to the gap of 172 (SD=108) days.

Results of the Tobit ModelTable 3 shows the results from the Tobit model. After controllingfor members’ other characteristics, the coefficient of cost-sharing was 0.019 (95% confidence interval [CI], 0.007-0.030,P=0.001). Interpreting the coefficients in a Tobit model can bechallenging because the marginal impact of X on Y is nonlinear.The approach is to take the Tobit estimate and multiply it by afactor to obtain the marginal impact. The factor is the standardnormal cumulative distribution function at the sample meanvalues of all the independent variables, which in our case was0.98 (almost 1). Therefore, the Tobit model suggests that start-ing at the mean values of all the independent variables includingcost-sharing, a $1 increase in cost-sharing was associated withan approximate 1.9% increase in total gap. Following transfor-mation of the cost-sharing coefficient, a $10 greater cost-sharewas associated with an approximate 18.9% increase in total gap(95% CI, 7.3%-30.4%).

Besides cost-sharing, 6 other significant independentpredictors were identified. A 1-year increase in age was associ-ated with an approximate 1.2% decrease in total gap. Residing inZip Code areas with a higher prevalence of white residents,using mail-order service, having an out-of-pocket annualmaximum on prescription drug spending, and having diagnosesof dyslipidemia and myocardial infarction were also associatedwith a lower total gap. Specifically, a 1% increase in the propor-tion of white people in the member’s Zip Code was associatedwith a 1.1% decrease in total gap; members who used mail-order service had a 86.4% lower total gap than those who didnot use mail-order service; members who had an out-of-pocketannual maximum on prescription drug spending had a 29.7%lower total gap than those who did not have this benefit; andmembers who were diagnosed with dyslipidemia and myocar-dial infarction had a 20.5% and 47.5% lower total gap comparedwith those who did not have these diagnoses, respectively.

Results of Logistic RegressionTable 4 shows the results from the logistic regression model.After adjusting for the control variables, a $1 increase in cost-sharing was associated with a 2.8% increase in the odds ofbeing nonpersistent (odds ratio [OR]=1.028, 95% CI, 1.011-1.045, P=0.001). Following transformation of the cost-sharingcoefficient, a $10 increase in cost-sharing was associated with a

Benefits Design Members (n) %

Mandatory generic substitution*

Yes 1,082 80.1

No 269 19.9

Formulary tiers†

1 copayment tier 62 4.6

2 copayment tiers 714 52.9

3 copayment tiers 575 42.6

Type of cost-sharing‡

Coinsurance only 6 0.4

Copayment only 1,011 74.8

Copayment and Coinsurance 334 24.7

Pharmacy deductible§

Yes 113 8.4

No 1,238 91.6

Yearly out-of-pocket maximum

Yes 613 45.4

No 738 54.6

Per-prescription out-of-pocket maximum¶

Yes 62 4.6

No 1,289 95.4

* Mandatory generic substitution is defined as the member’s benefit requires themember receive a generic when a generic identical chemical entity is available.

† The most common copayment single-tier was $15 ($30 for 90 days formail order), 2-tier was $15/$30 ($30/$60 for mail order), and 3-tier was$10/$20/$30 ($20/$40/$60 for mail order).

‡ The most common coinsurance rate was 20%.§ The most common pharmacy deductible was $100 per member per year .

The most common yearly out-of-pocket maximum was $1,500 per member or$2,500 per family .

¶ The most common out-of-pocket maximum per prescription was $40 ($120for mail order)

TABLE 1 Pharmacy Benefits Design (N=1,351)



Variables Copay Tertile 1 Copay Tertile 2 Copay Tertile3 Total P Value*

$0.00-$8.30n=452

$8.31-$13.00n=455

$13.01-$127.98n=444

$0.00-$127.98n=1,351

Mean initial cost-sharing per 30 days supply [SD] 6.29 [1.93] 9.45 [0.88] 21.71 [9.03] 12.42 [8.50] <0.001

Predisposing characteristics

Mean age in years [SD] 56.0 [12.7] 56.6 [12.8] 55.1 [13.7] 55.9 [13.1] 0.247

Female (%) 39.8 43.5 42.1 41.8 0.523

Other antihypertensives previously (%) 43.4 42.4 43.2 57.0 0.952

Mean % of white people in Zip Code [SD] 89.8 [13.2] 89.8 [12.4] 88.5 [13.9] 89.4 [13.2] 0.212

Enabling resources

Residence (%) 0.584

Urban 64.8 60.7 61.5 62.3

Rural 20.4 24.2 24.3 23.0

Super Rural† 14.8 15.2 14.2 14.7

Mean of the median income values for patients’ Zip Codes[SD]

47,642[14,480]

46,526[14,015]

44,902[14,751]

46,366[14,449]

0.017

Mean number of unique medications in prior 6 months [SD] 3.9 [3.5] 3.7 [3.3] 4.2 [3.6] 3.9 [3.5] 0.088

Initiated with ACEIs (%) 96.9 92.5 44.6 78.2 <0.001

Mail-order service in 6 months follow-up (%) 16.2 12.3 18.2 15.5 0.045

Mean number of doctor visits July 1, 2003-December 31, 2004 [SD] 6.4 [7.8] 5.9 [7.5] 4.7 [7.3] 5.7 [7.6] 0.003

Depression (%)‡ 15.7 15.0 15.5 15.4 0.946

Yearly out-of-pocket maximum (%) 53.8 47.9 34.2 45.4 <0.001

Need factors §

Essential hypertension 73.2 83.3 74.3 77.0 <0.001

Myocardial infarction 7.3 4.4 5.9 5.9 0.176

Congestive heart failure 8.4 6.2 5.9 6.8 0.251

Diabetes 31.4 25.7 28.4 28.5 0.164

Dyslipidemia 50.7 49.9 53.4 51.3 0.548

Cerebrovascular disease 5.1 4.0 6.8 5.3 0.167

Days supply

Mean total days supply in 6 months follow-up [SD] 164.7 [71.9] 143.0 [71.3] 142.4 [72.7] 150.1 [72.7] <0.001

Mean total mail-order days supply in 6 months follow-up [SD] 186.7 [78.3] 164.8 [71.3] 168.1 [69.1] 173.7 [73.3] 0.166

* The statistical tests used to derive these P values were chi-square test for categorical variables and analysis of variance (ANOV A) for continuous variables.† Super rural is defined as a rural area determined by the Secretary of Housing and Urban Development to be in the lowest 25th percentile of all rural populations

‡ Depression was identified by looking at whether a member used any antidepressant medications: mirtazapine (GPI code 580300), trazodone (58120080),monoamine oxidase inhibitors (581000), selective serotonin reuptake inhibitors (SSRIs, 581600), ser otonin-norepinephrine reuptake inhibitors (SNRIs, 581800),tricyclic agents (582000), and miscellaneous antidepressants (583000) in the prior 6 months.

§ Medical conditions in the “need factors” were identified using ICD-9-CM (the International Classification of Diseases-Ninth Revision-Clinical Modification)diagnosis and procedure codes recorded in medical claims between July 1, 2003 and December 31, 2004. Essential hypertension (IC D-9-CM 401.xx), myocardialinfarction (410.xx, 411.0x, 412.xx, 414.8x, 429.7x), congestive heart failure (398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93,425.4x, 428.xx), cerebrovascular diseases (362.34, 430.xx-438.xx, 784.3x, 997.02, 38.12 (P), 38.42(P), diabetes (250.xx), and dyslipidemia (272.xx).Mean mail-order days supply in 6 months follow-up is derived from those members who used mail-order service during the 6 months follow-up.

ACEI=angiotensin converting enzyme inhibitor

TABLE 2 Characteristics of Study Members (N=1,351)

arrayed by population density.49



31.9% increase in the odds of being nonpersistent (OR=1.319,95%CI, 1.120-1.553).

In addition to cost-sharing, 3 control variables were alsosignificant in predicting the odds of being nonpersistent. A1-year increase in age was associated with a 2.0% decrease in theodds of being nonpersistent. A 1% increase in the proportion ofCaucasians in the member’s Zip Code was associated with a 1.4%decrease in the odds of being nonpersistent. Members who usedmail-order service had a 43.0% lower odds of being nonpersis-tent compared to those who did not use mail-order service.

Results of the Cox Proportional Hazards ModelTable 5 presents the results of the Cox proportional hazardsmodel with the Breslow method for ties. Each $1 in cost shareper 30-day supply was associated with a 1.0% greater risk ofhaving a gap of more than 30 days in the coverage of ACEI orARB single agents (hazard ratio [HR]=1.010, 95% CI, 1.001-1.019, P=0.034). Following transformation of the cost-sharingcoefficient, a $10 increase in cost-share per 30-day supply wasassociated with a 10.2% increase in the risk of having a gap ofmore than 30 days (HR=1.102, 95% CI, 1.007-1.205).

Consistent with the Tobit model and logistic regression, age,residing in Zip Code census areas with a higher prevalence ofwhite residents, and using mail-order service were also signifi-cant predictors of the risk of having a gap of more than 30 daysin the coverage of ACEIs or ARBs. A 1-year increase in age wasassociated with a 1.1% decrease in the risk of having a gapof more than 30 days. A 1% increase in the proportion ofwhite residents in the member’s Zip Code was associated with a0.8% decrease in the risk of having a 30 day gap. Members whoused mail-order service had a 22.0% lower risk of having a gapof greater than 30 days than those who did not use mail-orderservice.

Figure 2 shows the estimated survival curves after adjust-ing for all control variables at the mean values in the Coxproportional hazards model. The survival curves were strati-fied by cost-sharing tertiles. The survivor function decreasesover time and more dramatically in the higher cost-sharingtertile. After up to 1 year of follow-up, 10% more members in thelowest cost-sharing tertile ($0.00-$8.30) were still persistent(i.e., not having a 30 day gap yet) compared with those in thehighest cost-sharing tertile ($13.01-$127.98).

nn DISCUSSIONAngiotensin system-blocking medication refill persistenceintensity and duration among members newly initiating therapywere consistently found to be independently associated withcost-share. In addition, the relationship between medicationpersistence and cost-share, quantified as $1 greater cost-share,was associated with a 1.9% larger medication gap during thefirst 6 months of treatment. To our knowledge, thesefindings are the first to quantify the relationship between

TABLE 3 Results of the Tobit Model to AssessAssociation Between Cost-Sharingand Total Gap (N=1,351)

Variables Coefficient 95% CI P Value

Initial cost-sharingper 30 days supply

0.019* 0.007 0.030 0.001


Age -0.012* -0.019 -0.005 0.002

Female 0.111 -0.065 0.286 0.216

Pre-use ofantihypertensives

0.100 -0.098 0.298 0.322

% of population self-reporting white race only

-0.011* -0.018 -0.004 0.001

Enabling resources

Living in rural area 0.153 -0.083 0.388 0.204

Living in superrural area†

0.076 -0.209 0.361 0.602

Household medianincome (thousands)

0.001 -0.007 0.008 0.888

Treatment for depression 0.093 -0.167 0.353 0.484

Initiated with ACEIs -0.017 -0.253 0.220 0.891

Unique medicationsin prior 6 months (n)

-0.021 -0.054 0.012 0.206

Mail-order service -0.864* -1.121 -0.608 <0.001

Doctor visits July 1, 2003-December 31, 2004 (n)

0.000 -0.013 0.014 0.953

Yearly out of pocketmaximum

-0.297* -0.489 -0.105 0.003

Need factors

Diagnosis of myocardialinfarction

-0.475* -0.853 -0.097 0.014

Diagnosis of congestiveheart failure

0.088 -0.265 0.440 0.626

Diagnosis ofcerebrovascular disease

0.397 0.005 0.789 0.050

Diagnosis of essentialhypertension

0.002 -0.206 0.209 0.986

Diagnosis of diabetes -0.077 -0.276 0.123 0.450

Diagnosis ofdyslipidemia

-0.205* -0.382 -0.029 0.023

Constant 4.884* 4.055 5.713 <0.001

* Denotes statistically significant comparison, P<0.05.LR x 2(20) = 147.35, P value<0.001, ACEI=angiotensin-converting enzyme inhibitor.† Super rural is defined as a rural area determined by the Secretary of Housing andUrban Development to be in the lowest 25th percentile of all rural populations arrayed bypopulation density.49



persistence and the amount of member cost-share for patientsnewly initiating angiotensin system-blocking medication.

Previously published studies focusing on pharmacy benefitdesign cost-sharing changes have shown minimal impact onantihypertensive persistence among current utilizers. These

studies are not comparable to the present study becausethe subjects were current users and because the effect of afixed benefit design change was being tested. In our cross-sectional study, members were newly initiating therapy and hadvariable per 30 day cost-share amounts ranging from $0 to $128

TABLE 4 Results of the Logistic Regressionto Assess Association BetweenCost-Sharing and Odds of BeingNonpersistent (N=1,351)

VariablesOddsRatio 95% CI P Value

Initial cost-sharing per30 days supply

1.028* 1.011 1.045 0.001


Age 0.980* 0.970 0.989 <0.001

Female 1.125 0.892 1.418 0.320

Pre-use of antihypertensives 1.187 0.915 1.540 0.197

% of population self-reportingwhite race only

0.986* 0.976 0.995 0.003

Enabling resources

Living in rural area 1.358 0.996 1.852 0.053

Living in super rural area† 1.172 0.806 1.703 0.407

Household median income(thousands)

1.001 0.991 1.010 0.906

Treatment for depression 0.871 0.618 1.227 0.429

Initiated with ACEIs 0.947 0.690 1.299 0.735

Unique medicationsin prior 6 months (n)

0.997 0.955 1.041 0.884

Mail-order service 0.570* 0.404 0.804 0.001


0.999 0.981 1.017 0.904

Yearly out of pocket maximum 0.907 0.704 1.168 0.449

Need factors


0.745 0.449 1.238 0.256

Diagnosis of congestiveheart failure

0.993 0.619 1.593 0.975

Diagnosis of cerebrovasculardisease

1.471 0.872 2.479 0.148


0.996 0.757 1.310 0.976

Diagnosis of diabetes 0.971 0.746 1.264 0.827

Diagnosis of dyslipidemia 0.843 0.668 1.064 0.150

* Denotes statistically significant comparison, P<0.05.LR x 2(20)=97.82, P value<0.001, ACEI=angiotensin-converting enzyme inhibitor.† Super rural is defined as a rural area determined by the Secretary of Housing andUrban Development to be in the lowest 25th percentile of all rural populations arrayed bypopulation density.49

TABLE 5 Results of the Cox Proportional HazardsModel to Assess Association BetweenCost-Sharing and Risk to Have a Gapof More Than 30 Days (N=1,351)

VariablesHazardRatio 95% CI P Value

Initial cost-sharing per30 days supply

1.010* 1.001 1.019 0.034


Age 0.989* 0.983 0.996 0.001

Female 1.124 0.966 1.308 0.131

Pre-use of antihypertensives 1.130 0.951 1.342 0.165

% of population self-reportingwhite race only

0.992* 0.987 0.997 0.003

Enabling resour ces

Living in rural area 1.150 0.942 1.404 0.169

Living in super rural area† 1.023 0.798 1.311 0.858

Household median income(thousands)

0.998 0.991 1.004 0.454

Treatment for depression 0.995 0.797 1.242 0.962

Initiated with ACEIs 0.925 0.759 1.129 0.445

Unique medications inprior 6 months (n)

0.998 0.971 1.027 0.901

Mail-order service 0.780* 0.627 0.969 0.025


1.003 0.991 1.015 0.641

Yearly out of pocket maximum 0.869 0.736 1.026 0.097

Need factors


0.908 0.648 1.272 0.575

Diagnosis of congestive heartfailure

1.093 0.808 1.478 0.565

Diagnosis of cerebrovasculardisease

1.265 0.916 1.747 0.153


0.972 0.812 1.164 0.761

Diagnosis of diabetes 0.921 0.774 1.097 0.359

Diagnosis of dyslipidemia 0.932 0.800 1.085 0.362

* Denotes statistically significant, P<0.05.LR x 2(20)=62.40, P value<0.001, ACEI=angiotensin-converting enzyme inhibitor.† Super rural is defined as a rural area determined by the Secretary of Housing andUrban Development to be in the lowest 25th percentile of all rural populations arrayed bypopulation density.49



allowing us to quantify the associated relationship between costshare and persistence.

The results of this study are comparable to the findings ofother persistence studies employing a cross-sectional studydesign. Among a combination of members currently utilizingand newly initiating statin therapy, Ellis et al. showed that high-er member cost-sharing amounts were associated with largedecreases in statin persistence rates.25 As compared withmembers who had a copayment of less than $10, members whopaid at least $10 but less than $20 and those who paid $20 orgreater had 30% and 211% greater odds of being nonpersistent(cumulative multiple refill interval gap [CMG]>20%),respectively. A 30% greater odds of being nonpersistent whencomparing a cost-sharing of $10 per 30 days supply to $20 issimilar to the finding in this study of a 31.9% increase in theodds of being nonpersistent for a mean $12 versus $22cost-sharing per 30 days supply. Taira et al. demonstrated thatcompliance with antihypertensive medications was significantlylower in higher than in lower copayment tiers.27 As comparedwith members who used generics with a copayment of $5,members who used preferred brand-name drugs with a copay-ment of a $20 and those who used non-preferred brand-namedrugs with a copayment of $20 to $165 had 24% and 52% lessodds of being compliant, respectively. Thiebaud et al. found thathigher cost-sharing was associated with lower statin utilization.49

They reported that a $1 increase in brand drug and genericcopay was associated with a 0.9% and 1.6% decrease in month-

ly days supply of brand drug and generics, respectively. Thesefindings are similar to our finding that a $1 increase in cost-shar-ing was associated with a 1.9% increase in total gap.

We found that age, percentage of population self-reportingwhite only race in the patient’s area of residence, and use of mail-order service were statistically significant predictors of total gap,being nonpersistent, and time to a gap of >30 days in the 3 mod-els. Some empirical studies have shown that age and race weresignificant predictors of medication persistence.31,36,38,40-41

Benner et al., for example, reported that members of black andother nonwhite races were less persistent with statin therapy.41

Although we also found a significant association betweenpersistence and race, this finding should be interpretedcautiously. Because claims data do not include race at theindividual level, we measured race at an aggregate level (i.e.,percentage of population in the patient’s Zip Code area self-reporting white as their only racial group).

In addition, results of this study suggest that members whofill prescriptions by mail-order pharmacies have greater persis-tence rates. However, the impact of mail-order service may beartificial because the calculation of persistence in this study wasbased on days supply recorded in pharmacy claims. Mail-orderpharmacies have larger days supply than community pharma-cies. Within a fixed observation period, members who receivemedications from mail-order pharmacies will have fewer refillsthan those who use community pharmacies and therefore theformer group will be less likely to have a gap. We believe theimpact of mail-order claims on our results is minimal becauseonly 8.3% of all the claims and 18.0% of total days supplyduring the first 6 months of treatment are mail-order. In addi-tion, mail-order was adjusted for in all 3 models. In order toremove the possibility of the impact of mail-order service on theoutcome, the 3 models were rerun with restriction to memberswith community pharmacy claims only. The impact of cost-shareon persistence did not change in all the 3 models (data notshown).

We also found that having an out-of-pocket annual maxi-mum on prescription drug spending and having diagnoses ofdyslipidemia and myocardial infarction were associated witha lower total gap in the Tobit model. We did not find similarrelationships with the odds of being nonpersistent and the riskof having an unallowable gap in the logistic regression and Coxproportional hazards models. These differences in independentpredictors between the Tobit model compared with the logisticregression and the Cox proportional hazards model may be dueto the fact that the Tobit model allows for persistence (total gap)as a continuous variable, while the logistic regression requirespersistence to be dichotomized (persistent vs. nonpersistent)and persistence is measured as time to an unallowable gap orduration in the Cox proportional hazards model.

We adapted Andersen’s behavioral model of health servicesuse as a conceptual framework to select important variables

FIGURE 2 Survival Estimates by Cost-Sharing Tertiles from the CoxProportional Hazards Model

0

20

40

60

80

100

0 65 92 122 150 180 218 298 381

Days Elapsed

Perc

ent

ofPe

rsis

tent

Mem

bers

Copay Tetile 1: $0.00-$8.30

2: $8.31-$13.00

3: $13.01-$127.98

Copay Tetile

Copay Tetile



to control in examining the relationship between cost-shar-ing and medication persistence. The results suggested thatAndersen’s model is valid as a guidance to select predictorvariables for examining medication persistence. In this study, forexample, the logistic model explained approximately 9% of thevariance in medication refill persistence (pseudo-R2=0.09). OurR2 value is improved over that of Cole et al., who reported an R2

value of 0.06.23

LimitationsThe primary limitation of this study is its cross-sectional

design, which is vulnerable to the effects of confoundingfactors. The 9% pseudo-R2 value in our logistic regression modelsuggests that a substantial portion of the variance in medicationrefill persistence was not explained by our model, a problemtypical of cross-sectional studies of this topic. Previous obser-vational work has indicated that patients initiating treatmentswith generic drugs (lower cost-share) have somewhat higheradherence rates than do those initiating with brand drugs (high-er cost-share); however, a randomized study is necessary for arigorous test of the effects of initial cost-share on early medicationpersistence.26 The need for further research is highlighted byrecent quasi-experimental (pre-post with comparison) study ofdiabetic supply utilization before and after the implementation ofa policy mandating provision of free diabetes supplies includingglucose testing strips to patients with diabetes mellitus. Cross-sectional analysis documented an association between highercost-sharing levels for the testing strips and lower compliancewith blood glucose testing guidelines prior to implementation.Yet implementation of the free test strip policy was not associat-ed with a change in adherence to testing guidelines, even amonglower-income patients and those paying the highest cost-shareprior to the policy change.50

Second, medication persistence is defined narrowly in thepresent study to include single-agent ACEI or ARB. Whileswitching between single-agent ARB or ACEI was permitted,drug therapy was considered terminated if the patient switchedto an ACEI or ARB in combination with hydrochlorothiazide(HCTZ) or to an antihypertensive in a different class such asa calcium channel blocker, diuretic, or a beta blocker. Third,our measurements of refill persistence depended on days supplyrecorded in pharmacy claims data. ACEI or ARB refill persistencemay be underestimated in this study because other sources foracquiring prescription medications, such as free samples fromphysicians, could not be identified in claims data.

Fourth, the subjects of this study may have self-selectedthe Midwest commercial insurer as their health plan. Althoughpharmacy benefits are usually the same within one health plan andsimilar across different health plans for the same employer, thisstudy may have been subject to a selection bias. However, to ourknowledge, the pharmacy benefits were the same regardless of thehealth benefits selected by the member within one employer.

Fifth, the members of this study were mostly younger than65 years. Therefore, the results of this study may not be general-izable to older adults.

Sixth, our results are limited to members newly initiating an-giotensin system-blocking agents and may not be generalizableto established medication users or other drug classes. Seventh,we attributed interruption of refills to members’ nonpersistencebehavior. However, these interruption decisions may have beenmade by physicians as a result of ineffectiveness or side effects.Nonetheless, these decisions should affect members with lowerand higher levels of cost-sharing equally. Eighth, some con-trol variables, including income and race, were measured onan aggregate Zip Code level instead of on the individual level.Ninth, the duration of this study may be of concern to somereaders. We followed the members for a minimum of 6 monthsand up to 1 year. The relatively short study duration was based onprevious research, which has shown that the largest decreasein antihypertensive persistence occurs between 3 and 6 monthsafter initiating therapy.40,51

Finally, in 2004, benazepril (Lotensin) and quinapril(Accupril) became generically available in February andDecember, respectively, resulting in lower member cost-sharing(i.e., generic cost-sharing). These 2 drugs were used by less than5% of ACEI users and exclusion of these members in sensitivityanalyses did not influence the results.

Policy ImplicationThis study has several implications for policy making. Payershave experimented with lowering medication cost-sharing forchronic diseases such as hypertension, hyperlipidemia, anddiabetes, where medication has been shown to prevent morbid-ity and mortality.52,53 Although zero-dollar member cost-sharingfor selected chronic conditions has been proposed, a startingpoint may be a zero-dollar or near zero-dollar cost-sharing forgeneric drugs, which has been adopted by some employers.54 Azero-dollar generic cost-share will potentially reduce cost to allbeneficiaries and improve persistence; however, to our knowl-edge, currently there are no well-controlled studies indicatingthat zero-dollar cost-sharing improves medication adherence.Knowing a relationship exists between how much an individualpays for medication and how long he or she will remainpersistent is the first step to improving pharmacy benefitsdesigns. We echo the statements made by others: “The challengeremains to make individuals more sensitive to the cost of treat-ment without encouraging them to forgo cost effective care.”52

nn CONCLUSIONThis study adds to the literature through further quantify-

ing the association between the amount of member prescriptioncost-share and medication refill persistence. Among membersnewly initiating an ACEI or ARB, a $10 greater cost-share wasassociated with 31.9% greater odds of being nonpersistent at



3. Kaiser Family Foundation and Health Research and Educational Trust.Employer Health Benefits – 2006 Annual Survey. Available at http://www.kff.org/insurance/7527/index.cfm. Accessed March 19, 2007.

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7. Gibson TB, Mark TL, McGuigan KA, et al. The effects of prescription drugcopayments on statin adherence. Am J Manag Care. 2006;12(9):509-17.

8. Huskamp HA, Deverka PA, Epstein AM, et al. The effect of incentive-basedformularies on prescription-drug utilization and spending. N Engl J Med.2003;349:2224-32.

9. Goldman DP, Joyce GF, Escarce JJ, et al. Pharmacy benefits and the use ofdrugs by the chronically ill. JAMA. 2004;291(19):2344-50.

10. Huskamp HA, Deverka PA, Epstein AM, et al. Impact of 3-tier formularieson drug treatment of attention-deficit/hyperactivity disorder in children. ArchGen Psychiatry. 2005;62(4):435-41.

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13. Kamal-Bahl S, Briesacher B. How do incentive-based formularies influ-ence drug selection and spending for hypertension? Health Aff (Millwood).2004;23(1):227-36.

14. Nair KV, Wolfe P, Valuck RJ, et al. Effects of a 3-tier pharmacy benefitdesign on the prescription purchasing behavior of individuals with chronicdisease. J Manag Care Pharm. 2003;9(2):123-33. Available at: http://www.amcp.org/data/jmcp/Research-123-133.pdf.

15. Rector TS, Finch MD, Danzon PM, et al. Effect of tiered prescription copay-ments on the use of preferred brand medications. Med Care. 2003;41(3):398-406.

16. Thomas CP, Wallack SS, Lee S, et al. Impact of health plan design andmanagement on retirees’ prescription drug use and spending, 2001. Health Aff(Millwood). July-December 2002(suppl Web exclusives):W408-19.

17. Landsman PB, Yu W, Liu X, et al. Impact of 3-tier pharmacy benefit designand increased consumer cost sharing on drug utilization. Am J Manag Care.2005;11(10):621-28.

18. Hillman AL, Pauly MV, Escarce JJ, et al. Financial incentives and drugspending in managed care. Health Aff (Millwood). 1999;18(2):189-200.

19. Berndt ER, Frank RG, McGuire TG. Alternative insurance arrange-ments and the treatment of depression: What are the facts? Am J Manag Care.1997;3(2):243-50.

20. Motheral BR, Henderson R. The effect of a copay increase on pharmaceuti-cal utilization, expenditures, and treatment continuation. Am J Manag Care.1999;5(11):1383-94.

21. Motheral BR, Fairman KA. Effect of a 3-tier copay on pharmaceutical andother medical utilization. Med Care. 2001;39:1293-304.

22. Fairman KA, Motheral BR, Henderson RR. Retrospective long-termfollowup study of the effect of a three-tier prescription drug copaymentsystem on pharmaceutical and other medical utilization and costs. Clin Ther2003;25(12):3147-61.

23. Cole JA, Norman H, Weatherby LB, et al. Drug copayment and adher-

6 months after initiating therapy. To our knowledge, this is thefirst study to quantify the association between the dollar amountof member cost-share and total gap in therapy among membersnewly initiating ACEI or ARB therapy. For every $10 greatercost-share, we found an associated 18.9% increase in totalmedication gap during the first 6 months of follow-up. Furtherresearch is needed to validate these findings and to investigatethis relationship among other antihypertensive drug classes andother chronic medications. Insurers should consider the impactthat cost-share has on angiotensin system-blocking medicationpersistence when designing their pharmacy benefit offerings.

ACKNOWLEDGMENTS

The authors thank Carol Walters, MBA, Senior Consulting Analyst, PrimeTherapeutics LLC, Eagan, MN, for her technical assistance in extracting thedata for analysis.

DISCLOSURES

An abstract of this manuscript was the basis of a podium presentation at the12th Annual International Meeting of the International Society of Pharmaco-economics and Outcomes Research (ISPOR) in May 2007. The authors discloseno bias or conflict of interest relating to this article.

Dongmu Zhang served as principal author of the study. Study conceptand design were contributed by Zhang and Angeline M. Carlson and StephenW. Schondelmeyer with input from Patrick P. Gleason, Jon C. Schommer, andBryan E. Dowd. Data collection was the work of Zhang with assistance fromSchommer, Carlson, Gleason, Schondelmeyer, and Alan H. Heaton; data inter-pretation was primarily the work of Zhange with input from Dowd, Carlson,Gleason, Schondelmeyer, and Schommer. Writing of the manuscript and itsrevision was primarily the work of Zhang with input from Gleason, Heaton,and Carlson.

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Authors

At the time the work was completed, DoNGMu ZHANG was a PhDcandidate, university of Minnesota, Minneapolis, MN. STEPHENW. SCHoNDElMEYER, PhD, and JoN C. SCHoMMER, PhD, areprofessors of Social and Administrative Pharmacy, and BRYAN E.DoWD, PhD, is professor of Health Policy and Management, univer-sity of Minnesota, Minneapolis, MN; ANGElINE M. CARlSoN, PhD,is president, Data Intelligence Consultants llC, Eden Prairie, MN;PATRICk P. GlEASoN, PharmD, is Director of Medical and PharmacyIntegration Services, Prime Therapeutics llC, Eagan, MN; AlAN H.HEAToN, PharmD, is Director of Pharmacy, BlueCross BlueShield ofMinnesota, Eagan, MN.

CoRRESPoNDING AuTHoR:Dongmu Zhang, PhD, Statistical Services, IMS Health, 960A HarvestDrive, Blue Bell, PA 19422. Tel.610-832-5808; Fax: 610-832-5850;E-mail: [email protected]



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The escalating role of prescription pharmaceuticals indisease management, particularly among older adults,has focused greater attention on the nature of the

pharmaceutical dispensing environment. Mail-order pharmacieshave emerged as an alternative to store-front pharmacies forreducing dispensing-related costs and dispensing errors throughcentralization and automation,1 but the extent to which a mail-order pharmacy option is available to consumers or the factorsthat influence their use of that option are not clear. Survey-basedstudies consistently report high consumer satisfaction withinsurance plans that include a mail-order pharmacy option,but it is unclear whether ratings are driven by the financialincentives associated with using a mail-order option or apreference for one pharmacy setting over another.2-5

Like many health care plans, the Department of Defense(DoD) health care plan, TRICARE, has incorporated a mail-order option to help curb the rising cost of its prescription drugbenefit. The TRICARE drug plan offers beneficiaries the optionof filling prescriptions at military pharmacies, at communitypharmacies, or through the centralized TRICARE mail-order

BACKGROUND: Department of Defense (DoD) health care planners want tostimulate a voluntary migration of prescription fills from military and com-munity pharmacies to its mail-order pharmacy, a lower-cost dispensing optionfor the department. Beneficiary cost share for a 90-day supply of generic/brand medication is $0/$0 at military (DoD) pharmacies, $3/$9 at the DoDmail-order pharmacy, and $9/$27 at network community pharmacies.

OBJECTIVE: To examine the pharmacy use patterns among the beneficiarypopulation age 65 years or older, traditionally the heaviest users of theTRICARE DOD prescription drug benefit, to identify factors that are associatedwith beneficiary use of pharmacy setting(s).

METHODS: Outpatient prescription fill records were examined for TRICAREbeneficiaries age 65 years or older (N = 300,084) residing in North Carolina,Texas, and California for dates of service from December 1, 2004 throughFebruary 28, 2005. Binary logistic regression models were run for each type(military, community, and mail order) and number of pharmacy settings usedby beneficiary gender, age group, catchment area status (located either withinor outside a 40-mile radius of each military pharmacy), state, and number ofmedications obtained (defined as count of unique combinations of strength,and route of administration). The mean number of medications per benefi-ciary and cost per medication were tabulated for each type and number ofsettings used.

RESULTS: In the 3-month period from December 1, 2004 through February 28,2005, beneficiary use of military, community, and mail-order pharmacies was45.4%, 67.6%, and 22.1%, respectively. About 67% of the study populationused 1 setting exclusively and 2.4% used all 3 settings. Noncatchmentresidents were significantly less likely (adjusted odds ratio [AOR]= 0.080;95% confidence interval [CI], 0.078-0.082) to use a military pharmacyexclusively and significantly more likely to use a community pharmacy (AOR= 4.64; 95% CI, 4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI,3.80-4.05) exclusively than were catchment residents. Beneficiaries taking10 or more medications were more likely (AOR = 8.43; 95% CI, 8.21-8.65) touse multiple settings than were those who obtained 3 or fewer medications.Single-setting users obtained a median of 4 (interquartile range [IQ]) 2-7)medications with a median copayment of $7.00 (IQ $0-$13.19) per medica-tion. Those who used all 3 settings obtained a median of 9 (IQ 7-12) medica-tions with a median copayment of $4.33 (IQ $3.00-$6.00) per medication.Among beneficiaries who obtained 6 or more unique medications during the90-day study period, approximately 25% used the mail-order pharmacy toobtain 1 or more prescription fills.

CONCLUSION: A significant portion of the study population did not use themail-order pharmacy despite the financial incentive to use mail-order ratherthan community pharmacies. Relatively small financial incentives alone maybe inadequate for promoting a switch to the mail-order option among thosebeneficiaries not already using it in a pharmacy benefit plan with low copay-ments. Larger monetary and other incentives may be necessary to achievethe desired transfer of prescriptions fills to the mail-order pharmacy and theassociated reduction in military pharmacy workload.

KEYWORDS: Department of Defense, Mail-order pharmacy, TRICARE

Factors Associated With Choice of Pharmacy SettingAmong DoD Health Care Beneficiaries Aged 65 Years or Older

Andrea Linton, MS; Mathew Garber, PhD; Nancy K. Fagan, DVM, PhD;and Michael Peterson, DVM, DrPH

ReSeARcH




• Among beneficiaries aged 65 years and older, a small financialincentive ($6 generic/$18 brand out-of-pocket cost savingsper 90-day supply) may not be sufficient to achieve a widespread voluntary shift from community pharmacies to themail-order pharmacy.

• Geographic proximity to a military pharmacy contributessignificantly to the choice of setting.

• The strongest predictor of aged 65+ beneficiaries’ decisionmaking regarding their prescription purchases is the number ofunique medications used.

• Many health plans have incorporated mail-order pharmacyas a potentially lower-cost alternative to community pharmacy..

ABSTRAcT



pharmacy (TMOP). DoD purchases medications under afederally mandated pricing structure that allows it to stockmedications at its military pharmacies and at TMOP at a lowercost than the reimbursements paid to community pharmaciesused by TRICARE beneficiaries.

TMOP and the military pharmacies are also able to dispensemedications less expensively through centralization and formu-lary management, and savings are passed on to beneficiaries inthe form of reduced cost shares. Thus, DoD has determined thata shift of workload out of the community pharmacies into themilitary pharmacies and TMOP would be cost-effective for thedepartment and reduce copayments for the beneficiaries. Manymilitary pharmacies, however, already face a heavy workloadserving active duty personnel and their families. Rather thanfurther strain the capacity at military pharmacies, DoD wants tomotivate a voluntary migration into TMOP, particularly by age65+ beneficiaries who are the largest consumers of prescriptionmedications. To accomplish this migration, planners requirea better understanding of the factors associated with age 65+beneficiary use of each pharmacy setting.

We examined a 90-day census of prescription data for asample of age 65+ DoD health care beneficiaries who used theirTRICARE benefit to fill their prescriptions. Our objective was tocharacterize the users of each pharmacy setting and identify keyfactors associated with use of the mail-order pharmacy option.

nn The TRICARE Pharmacy BenefitThe TRICARE pharmacy benefit is available to all DoD benefi-ciaries, including those 65 years and older. The DoD seniorbeneficiary population comprises primarily career militaryservice retirees, their spouses, and survivors of deceased servicemembers. Senior veterans and their dependents are eligible forTRICARE when they have completed a full military careerbefore retiring from military service. Beneficiaries require only avalid DoD identification card and a written or electronicprescription from their doctor to use their pharmacy benefit.Beneficiaries may use their TRICARE pharmacy benefit withoutusing any other health care services offered under TRICARE.

The TRICARE pharmacy benefit covers most prescrip-tion medications as well as some over-the-counter products(e.g., diabetic supplies). TRICARE does not impose a cap onthe drug benefit, but it does place quantity limits andprior authorization requirements on specific medications.TRICARE policy mandates that all prescriptions be filled with ageneric product if one is available. However, exceptions may bemade to this policy in military pharmacies and in TMOP ifDoD can dispense a brand medication at a lower cost than itsgeneric equivalent.

The military pharmacies generally stock medicationsacross all drug classes, but the breadth of inventory may benarrower than for community pharmacies and TMOP, depend-ing on the size of the military pharmacy and the nature of the

beneficiary population it supports. For example, the militarypharmacy may stock only the generic form or a single brandof a medication in a given drug class, such as genericomeprazole and brand rabeprazole, but not brand omeprazole,lansoprazole, pantoprazole, or esomeprazole in the class ofproton-pump inhibitors. TMOP typically offers the same breadthof brand and generic medications that is available fromcommunity pharmacies.

During our study period, a beneficiary’s cost share dependedon the pharmacy setting and whether the drug was generic orbrand, as shown in Table 1. Military and mail-order pharmaciescould dispense up to a 90-day supply of medication at a time,free of charge or with 1 copayment, respectively. Communitypharmacies charged 1 copayment for each 30-day (or less)supply of medication. A 90-day supply was the maximumamount of medication that could be dispensed at a time fromany pharmacy setting. Thus, a 90-day supply of medicationwould be associated with a copayment of $0 at a militarypharmacy, $3 or $9 at TMOP, and $9 or $27 at a networkcommunity pharmacy for generic and brand medications,respectively. Use of non-network pharmacies has higherassociated cost shares for the beneficiary and is an option usedprimarily by beneficiaries residing overseas and in remotelocations in the United States.

DoD contracts with Express Scripts Inc., a private company,to administer the TRICARE mail-order pharmacy program.Beneficiaries may fill prescriptions by mail, phone, or fax, oronline, and any beneficiary may use the mail-order option.Beneficiaries who have prescription drug coverage from otherhealth insurance (OHI), however, can use the TRICARE mail-order pharmacy only if (1) the medication is not covered undertheir OHI or (2) they have exceeded the dollar limit of coverageunder their OHI. Federal law mandates that OHI is the first pay-er for mail-order prescription services for TRICARE beneficiaries

TABLE 1 Beneficiary Copayment Amount andMaximum Days Supply per Copaymentfor Generic and Brand Medications byPharmacy Setting Used

MilitaryPharmacy

NetworkCommunity

Non-networkCommunity

MailOrder

Generic

Brand

*The larger of the 2 amounts is paid after a point-of-service deductible is applied; thedeductible is usually $150 per sponsor (military service beneficiary) or $300 per family.

$0 $3 $9 or 20%* $3

$0 $9 $9 or 20%* $9

90 days 90 days30 days30 days

Type ofMedication

MaximumSupplyPer Copay



who carry OHI, because OHI may not be used topurchase medications obtained under the federal pricingstructure.6 Beneficiaries who wish to use their OHI and theirTRICARE benefit to obtain medications covered under bothplans are directed to a network community pharmacy. The useof OHI by study beneficiaries to purchase prescription medica-tion occurred infrequently.

nn MethodsDoD maintains an enterprise-wide information system thatcaptures patient demographic and prescription information foreach prescription filled by a beneficiary using his or her TRI-CARE pharmacy benefit. A fill record is created in real timewhen the prescription is filled, regardless of whether a militaryor community pharmacy or TMOP is used. The fill records areforwarded to a central data repository for processing to removetransactions that have been reversed (e.g., prescriptions thatwere filled but never picked up) and coded with an auto-gener-ated, encrypted patient identifier that enables researchers to linkpharmacy and health care service records for the same personwithout including any protected health information in the studydatasets. This data repository was the source for the data usedin this study.

We examined prescription fill data for residents in 3 targetstates—North Carolina, Texas, and California—to account forthe possibility of regional differences in pharmacy use. Eachstate represents 1 of the 3 TRICARE regions nationwide—North(North Carolina), South (Texas), and West (California)—in which the uniform health care benefit is independentlyadministered. Each of these states also contains a large age 65+beneficiary population and multiple military pharmacies wherebeneficiaries may obtain prescription medication at no out-of-pocket cost. Collectively, these 3 states comprise approximately25% of the age 65+ DoD beneficiary population nationwide.

A census of outpatient pharmacy fill records for beneficia-ries aged 65 years and older who resided in the target statesfor a 90-day period (December 1, 2004 through February 28,2005) was extracted from this central repository. Fill recordsassociated with the 171 beneficiaries who relocated from orto a target state during the study period were eliminated fromthe sample. Approximately 0.7% of the fill records were thenexcluded from the dataset because they were missing data orthey represented medications administered by a clinicianduring a clinic visit. The resulting 2,726,608 fill records wereaggregated into unique beneficiary records that included allprescriptions filled during the study period. The final studydataset included fill records corresponding to 1,857,268 uniquemedications dispensed to 300,084 beneficiaries.

The number and percentage of beneficiaries residing in eachtarget state were tabulated by beneficiary gender, age group andcatchment status, number of prescription medications obtained,types of pharmacy settings used, and number of pharmacy

settings used during the 90-day study period. Beneficiaries werecategorized as catchment residents if they resided within a40-mile, ZIP code-based radius of a military hospital (housing alarge military pharmacy with a large drug inventory) or withina 20-mile, ZIP code-based radius of a military clinic (housing asmaller military pharmacy with a smaller drug inventory). DoDestablished these hospital and clinic catchment areas to defineits health care service areas and perform demand forecasting andmanagement analyses to ensure sufficient capacity for thebeneficiary population. Beneficiaries who did not reside withinthese areas were designated as noncatchment residents. Thenumber of medications was defined as the total number ofunique medications filled during the study period, as identifiedby the First DataBank generic code number (GCN). Each GCNspecifies the active ingredient, strength, dosage form, and routeof administration and provides a method of linking brand drugswith generic equivalent products (i.e., simvastatin 20 mgshares a GCN with Zocor 20 mg). Thus, each drug (e.g.,simvastatin) has multiple GCNs—a GCN for each uniquecombination of drug strength, and route of administration

Binary logistic regression models were run to predict use ofeach type of pharmacy setting exclusively and the total numberof settings used, by beneficiary gender, age group, catchmentstatus, target state, and number of medications obtained. In theequations predicting use of the pharmacy setting, the dependentvariable was coded “1” if the setting was used exclusively, and“0” if it was not. For the equation predicting number of settings,the dependent variable was coded “0” if only 1 pharmacy settingwas used, or “1” if multiple pharmacy settings were used to fillprescriptions during the study period. Backwards stepwiseregression was applied using the likelihood ratio statistic(P<0.05) to eliminate variables that did not significantlycontribute to use of the setting. The c-statistic was used toevaluate model discrimination. Interaction terms using gender,age group, and catchment status were initially included in themodels, but later removed since they did not improve modeldiscrimination.

Finally, the median and interquartile range (IQ) for thenumber of medications obtained, the patient expenditure, andthe patient cost per medication was calculated. All data manipu-lations and analyses were performed using Statistical Package forSocial Sciences (SPSS), Base 10.0. This study was reviewedby the TRICARE Management Activity exempt determinationofficer on November 21, 2005, and found to be exempt frominstitutional review board review under 32 CFR 219.101(b)(4).

nn ResultsThe number and percentage of TRICARE pharmacy benefitusers by gender, age group, catchment status, and use character-istics in each target state are presented in Table 2. Womenoutnumbered men in each target state, and the mean age ofresidents ranged from 73.1 (SD ±6.1) years in North Carolina to



North Carolina

Total beneficiaries 48,607 100.0 119,952 100.0 131,525 100.0 300,084 100.0

Gender

Men 22,871 47.1 55,431 46.2 58,980 44.8 137,282 45.7

Women 25,736 52.9 64,521 53.8 72,545 55.2 162,802 54.3

Age group (years)

65-69 16,707 34.4 36,412 30.4 31,999 24.3 85,118 28.4

70-74 14,786 30.4 34,687 28.9 32,746 24.9 82,219 27.4

75-79 9,044 18.6 22,709 18.9 27,262 20.7 59,015 19.7

80-84 5,496 11.3 17,452 14.5 25,058 19.1 48,006 16.0

85+ 2,574 5.3 8,692 7.2 14,460 11.0 25,726 8.6

Mean agein years [SD]

73.1 [6.1] 73.9 [6.5] 75.4 [6.9] 74.4 [6.7]

Catchment status

Catchment residents 21,039 43.3 68,303 56.9 80,761 61.4 170,103 56.7

Noncatchment residents 27,568 56.7 51,649 43.1 50,764 38.6 129,981 43.3

Number of unique medicationsobtained

1-3 13,644 28.1 33,370 27.8 43,201 32.8 90,215 30.1

4-5 10,155 20.9 24,832 20.7 29,786 22.6 64,773 21.6

6-9 14,531 29.9 36,302 30.3 37,916 28.8 88,749 29.6

10+ 10,277 21.1 25,448 21.2 20,622 15.7 56,347 18.8

Mean medications obtained [SD]* 6.5 [4.3] 6.5 [4.3] 5.8 [4.0] 6.2 [4.2]

Type of settings used†

Military pharmacy 20,988 43.2 57,938 48.3 57,379 43.6 136,305 45.4

Community pharmacy 35,823 73.7 79,481 66.3 87,609 66.6 202,913 67.6

Mail-order pharmacy 9,996 20.6 25,951 21.6 30,521 23.2 66,468 22.1

Number of settings used

1 pharmacy setting 31,623 65.1 79,540 66.3 90,442 68.8 201,605 67.2

Military pharmacy only 9,085 18.7 31,089 25.9 31,045 23.6 71,219 23.8

Community pharmacy only 19,731 40.6 41,328 34.5 49,367 37.5 110,426 36.8

Mail-order pharmacy only 2,807 5.8 7,123 5.9 10,030 7.6 19,960 6.7

2 pharmacy settings 15,768 32.4 37,406 31.2 38,182 29.0 91,356 30.4

3 pharmacy settings 1,216 2.5 3,006 2.5 2,901 2.2 7,123 2.4

*Mean number of medications obtained during the study period (refills excluded).†Categories are not mutually exclusive since beneficiaries may use multiple settings to obtain medication.

TABLE 2 Number and Percentage of Beneficiaries by Demographic and Pharmacy Use Characteristicsby Target State

n %

Texas California Total

n % n % n %Variable



75.4 (SD ±6.9) years in California. The percentage of catchmentarea residents ranged from 43.3% in North Carolina to 61.4% inCalifornia. The mean number of medications obtained duringthe study period ranged from 5.8 (SD±4.0) medicationsin California to 6.5 (SD ±4.3) medications in both NorthCarolina and Texas. In all target states, community pharmacieswere most frequently used by beneficiaries and TMOP was usedthe least. Approximately 67% of residents in all target states used1 pharmacy setting exclusively and only 2.4% used all 3pharmacy settings during the study period.

The adjusted odds ratios (AORs) and 95% confidenceintervals (CIs) for the binary logistic regression for each type ofpharmacy setting used exclusively during the study period arepresented in Table 3. Women were significantly more likely thanmen to use community pharmacies exclusively (AOR = 1.36;95% CI, 1.34-1.39), and men are more likely to be exclusiveusers of the other 2 settings. Military pharmacy use decreasedand community pharmacy use increased with increasingbeneficiary age. Use of TMOP exclusively peaked with the70 to 74-year age group (AOR =1.14; 95% CI, 1.10-1.19) butremained relatively constant compared with patterns observedfor other pharmacy settings.

Noncatchment area residents were less likely (AOR = 0.080;95% CI, 0.078-0.082) to use a military pharmacy and were morelikely to use a community pharmacy (AOR = 4.64; 95% CI,4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI,3.80-4.05) than were catchment area residents. Texas residentswere more likely to use military pharmacies exclusively (AOR =1.41; 95% CI, 1.38-1.44). North Carolina residents were morelikely to use community pharmacies exclusively (AOR = 1.08;95% CI, 1.05-1.12). California residents had a higher likelihoodof using the mail-order pharmacy than did residents of were theother 2 states. The likelihood of using the community pharmacysetting exclusively increased as the number of medicationsobtained increased. The values of the c-statistic indicate that themodels accurately predicted 72.0%, 72.5%, and 79.8% of theobserved use of mail order, community pharmacy, and militarypharmacy settings, respectively.

The AORs and 95% CIs for the binary logistic regression forthe number of pharmacy settings used during the study periodare presented in Table 4. Single-setting use was morecommon among women (AOR =1.10; 95% CI, 1.08-1.12) andnoncatchment residents (AOR = 1.20; 95% CI, 1.18-1.22) andgenerally increased with increasing patient age. Variations in thenumber of settings used by target state were generally small.Single-setting use decreased and multiple-setting use increasedsubstantially as the number of medications obtained increased.Beneficiaries taking 10 or more medications were more likely(AOR = 8.43; 95% CI, 8.21-8.65) to use multiple pharmacysettings than were those who obtained 3 or fewer medicationsduring the 90-day study period. The values of the c-statisticindicate that the models accurately predicted 70.9% of the ob-

served setting use.Table 5 presents the median and IQ ranges for the number of

medications obtained, the total patient expenditure, and thecost per medication during the 90-day study period for thetypes and number of pharmacy settings used. Users of militarypharmacies exclusively incurred the lowest median patientexpenditures ($0) and cost per medication ($0), and users ofcommunity pharmacy exclusively incurred the highestmedian patient expenditures ($57.00 [IQ, $17.00-$105.00])and cost per medication ($12.21 [IQ, $8.87-$17.00]). Overall,as the number of pharmacy settings used increased, the mediannumber of medications obtained and median patient expendi-ture increased but the median cost per medication decreased.Beneficiaries who used only 1 pharmacy setting obtained amedian of 4 (IQ, 2-7) medications and paid a median cost of$7.00 (IQ, $0-$13.19) per medication. Those who used all 3pharmacy settings obtained a median of 9 (IQ, 7-12) medica-tions and paid a median cost of $4.33 (IQ, $3.00-$6.00) permedication.

A graphical presentation of the relative percentage ofmail-order users and nonusers by the number of medicationsobtained during the study period is presented in the Figure.The percentage of beneficiaries using mail order increased as thenumber of medications obtained increased, but the percentageof mail-order nonusers exceeded the percentage of mail-orderusers by a factor of 2 to 3, regardless of the number of medica-tions obtained.

nn DiscussionOur findings indicate that the strongest predictor of age 65+beneficiaries’ decision making regarding their prescriptionpurchases is the number of medications (as defined by uniqueGCN) they obtain. Beneficiaries who obtained relatively fewmedications were more likely to obtain all their medicationsfrom a single pharmacy setting, and residential proximity to amilitary pharmacy contributed significantly to the choice ofsetting used. Not surprisingly, catchment residents were morelikely to use military pharmacies, where all prescriptionmedications were obtained at no cost to the beneficiaries. Thosewho lived outside the catchment areas were more likely to usecommunity pharmacies or the mail-order pharmacy, despite thecopayment requirements associated with the use of bothsettings. This finding suggests that the out-of-pocket costsincurred by use of these pharmacies were preferable to spendingthe time, energy, or expense of travel to a source of copayment-free medications. This finding is consistent with survey-basedfindings that found convenience to be a primary considerationin consumers’ choice of pharmacy.7

The relationship between catchment status and beneficiarydecision making diminished among heavier consumers ofprescription medication, who were more likely to use multipletypes of pharmacies to obtain their medication. These findings



are consistent with prior studies that found that maintenancemedication users are skilled at identifying the most cost-effec-tive source for each medication they use and more motivatedto obtain each medication from the source that will minimizetheir own out-of-pocket expenses.8-10 Beneficiary gender andage were lesser but still significant contributors to beneficiaries’use of each type of pharmacy. Women and older adults, who aretraditionally the heaviest users of prescription medication, weresignificantly more likely to use only 1 type of pharmacy setting,likely a community pharmacy, to obtain their medications. Menand younger seniors had a higher likelihood of using multiplesettings, military pharmacies, and the mail-order option.

In general, we found that state of residence was a relativelyminor contributor to age 65+ pharmacy use patterns comparedwith other factors examined. We found, however, that Califor-nia residents obtained the lowest mean number of medicationsper beneficiary despite having the highest mean beneficiary age.They were also more likely to use TMOP than were residents ofNorth Carolina and Texas, despite having higher proportions ofcatchment area residents. It is not clear whether these observa-tions are attributable to the differences in regional administra-tion of the TRICARE benefit or a larger phenomenon associatedwith a regional or California-specific health care culture. Ourfindings are consistent with a prior Express Scripts study that

Military Pharmacy Only Community Pharmacy Only Mail Order Only

AOR 95% CI AOR 95% CI AOR 95% CI

Gender

Men*

Women 0.72 0.70-0.73† 1.36 1.34-1.39† 0.92 0.89-0.94†

Age group (years)

65-69* *

70-74 0.90 0.88-0.93† 1.03 1.01-1.06† 1.14 1.10-1.19†

75-79 0.70 0.68-0.73† 1.28 1.24-1.31† 1.11 1.06-1.16†

80-84 0.50 0.48-0.52† 1.72 1.66-1.77† 1.07 1.02-1.12†

85+ 0.36 0.35-0.38† 2.33 2.25-2.42† 0.92 0.86-0.97†

Catchment status

Catchment residents* *

Noncatchment residents 0.080 0.078-0.082† 4.64 4.55-4.73† 3.92 3.80-4.05†

State of residence

California* *

North Carolina 1.17 1.13-1.21† 1.08 1.05-1.12† 0.61 0.58-0.64†

Texas 1.41 1.38-1.44† 0.84 0.82-0.86† 0.77 0.74-0.79†

Number of uniquemedications obtained

1-3* *

4-5 1.11 1.08-1.14† 0.97 0.95-1.00 0.89 0.85-0.92†

6-9 1.02 1.00-1.05 1.24 1.21-1.27† 0.56 0.54-0.58†

10+ 0.795 0.768-0.823† 1.92 1.86-1.98† 0.19 0.18-0.21†

C-statistic (95% CI) 0.798 0.725 0.7200.791-0.804 0.718-0.732 0.709-0.731

TABLE 3 Adjusted Odds Ratios and 95% Confidence Intervals for Binary Logistic RegressionModels Predicting Exclusive Use of Military Pharmacies, Community Pharmacies,and the Mail-Order Pharmacy by Beneficiary Characteristics

*Used as the reference value for the logistic regression.†A statistically significant difference relative to the reference value.The numbers of beneficiaries using military or community pharmacies or the mail-order pharmacy exclusively were 71,219, 110,426, and 19,960, respectively. The number ofbeneficiaries included in each of the 3 equations was 201,605.AOR = adjusted odds ratio; CI = confidence interval.

* * * * * *

*

*

*

*

*

*

*

Variable



TABLE 4 Adjusted Odds Ratios and 95% Confidence Intervals for Binary Logistic Regression ModelsPredicting Use of 1 and Multiple Pharmacy Settings, by Beneficiary Characteristics

*Used as the reference value for the logistic regression.†A statistically significant difference relative to the reference value. The number of beneficiaries using 1 setting was 201,605, and 98,479 beneficiaries used multiplesettings.The number of beneficiaries included in the equation was 300,084.C-statistic (95% CI) = 0.709 (0.703 - 0.715).AOR = adjusted odds ratio; CI = confidence interval.

1-Setting Users Multiple-Setting Users

AOR 95% CI AOR 95% CI

Gender

Men* * * * *

Women 1.10 1.08-1.12† 0.91 0.89-0.92†

Age group (years)

65-69* * * * *

70-74 0.91 0.89-0.93† 1.10 1.07-1.12†

75-79 1.00 0.98-1.03 1.00 0.98-1.02

80-84 1.18 1.15-1.21† 0.85 0.83-0.87†

85+ 1.59 1.54-1.65† 0.63 0.61-0.65†

Catchment status

Catchment residents* * * * *

Noncatchment residents 1.20 1.18-1.22† 0.83 0.82-0.85†

State of residence

California* * * * *

North Carolina 0.94 0.92-0.96† 1.06 1.04-1.08†

Texas 1.02 1.00-1.03 0.98 0.97-1.00

Number of unique medications obtained

1-3* * * * *

4-5 0.30 0.30-0.31† 3.30 3.21-3.38†

6-9 0.18 0.18-0.18† 5.58 5.45-5.72†

10+ 0.12 0.12-0.12† 8.43 8.21-8.65†

Variable

nMedian Number of

Medications (IQ) Obtained*Median Patient Expenditure

(IQ; $)†Median Patient Costper Medication (IQ; $)‡

All beneficiaries 300,084 5 (3-8) 27.00 (0.00-63.00) 6.75 (0.00-10.82)

One pharmacy setting used 201,605 4 (2-7) 18.00 (0.00-66.00) 7.00 (0.00-13.19)

Military pharmacy only 71,219 4 (2-7) 0.00 (0.00-0.00) 0.00 (0.00-0.00)

Community pharmacy only 110,426 5 (2-8) 57.00 (17.00-105.00) 12.21 (8.87-17.00)

Mail-order pharmacy only 19,960 3 (2-5) 24.00 (12.00-39.00) 7.00 (6.00-9.00)

Two pharmacy settings used 91,356 7 (5-10) 36.00 (18.00-63.00) 5.57 (2.77-8.09)

All pharmacy settings used 7,123 9 (7-12) 39.00 (24.00-60.00) 4.33 (3.00-6.00)

*Median and IQ range for number of unique medications obtained during the study period.†Median and IQ range for out-of-pocket expenditures during the study period (cost of refills included).‡Median and IQ range for cost per medication obtained during the study period (cost of refills included).IQ = interquartile.

TABLE 5 Median Number of Medications Obtained, Patient Expenditure, and Cost per Medication by Typeand Number of Pharmacy Settings Used

Pharmacy Settings



found California had one of the lowest per-member per-yearprescription medication use averages in the country.11

Increased use of mail-order pharmacies by seniors nation-wide has been reported in recent years, presumably as a result ofdrug plan incentives that increase the days supply ofmedication obtained per copayment dollar spent.12 Clearly, theexisting TRICARE copayment structure contains this type offinancial incentive to promote use of TRICARE’s mail-orderpharmacy over community pharmacies. Our findings suggest,however, that the relatively small out-of-pocket generic/brandcost savings of $6/$18 per 90-day supply of medication has beeninadequate for motivating many community pharmacy users touse the mail-order option. Furthermore, use of militarypharmacies by 45% of age 65+ beneficiaries to obtain copay-ment-free prescription medications is less expensive for DoDbut places a strain on the capacity of military pharmacies, whosefirst priority is the treatment of active duty personnel so thatthey may return to duty.

Anecdotal evidence suggests that many beneficiaries, partic-ularly retired active duty personnel, view the trip to the militaryinstallation as an opportunity to not only obtain free medica-tions, but also shop at the commissary and coordinate visits withformer colleagues and other retired service members. Thus, itis not clear that a reduction or elimination of the copaymentrequirement under the mail-order program, currently under

consideration by DoD planners, would provide an adequateincentive for the 78% of the beneficiaries who are not mail-order users to begin using TMOP.

The literature includes successful examples of formularycopayment restructuring to motivate the use of generic orpreferred medications.13-14 Several studies have also observedhigher mail-order use among populations covered by planswith larger financial incentives.15-16 But few data are availablethat directly measure changes in mail-order use followingimplementation of financial incentives that promote voluntarymail-order pharmacy use.

Given the relative convenience and cost savings associatedwith the existing mail-order program, particularly for noncatch-ment residents, the low use suggests that beneficiaries mayeither be unaware of the program or unable or unwilling to useit. Beneficiaries who have traditionally relied on the pharmacistfor advice may view the mail-order option with skepticism,particularly older patients who may have a lower comfort levelwith the concept of a “virtual” drugstore. Any changes to theTRICARE prescription drug benefit should be accompanied by asignificant patient education and marketing effort thatfocuses attention on the benefits and ease of using the mail-order program.

These findings highlight the challenge faced by DoD tostimulate a voluntary migration of the workload associ-

FIGURE Percentage of Beneficiaries by Number of Medications Obtained for Mail-Order Users and Nonusers

16.822.5 24.8 26.1

83.277.5 75.2 73.9

0

10

20

30

40

50

60

70

80

90

100

1-3 4-5 6-9 10+

Number of Medications Obtained

Percentage

ofAge

65+Beneficiaries

Mail-Order UsersNonmail-Order Users

n = 88,749 n = 56,347n = 90,215 n = 64,773



ated with pharmacy benefits for the aged 65+ population toTMOP. Among the study population, approximately two thirdsof beneficiaries aged 65 or older elected to use a communitypharmacy for some or all of their medications, despite it being themost expensive option under the TRICARE pharmacy benefit.Perhaps this choice is because even in community pharmacies, thecopayment requirements imposed on TRICARE beneficiaries aresubstantially lower than those imposed on other insuredpopulations. A national survey of health benefits reportedaverage prescription copayments of $10, $22, and $35 forgeneric, preferred, and nonpreferred formulary medications,respectively, for insured workers in 2005.17 TRICARE beneficia-ries have a relatively rich pharmacy benefit, and the financialincentive to use mail-order pharmacy is small.

It is important to note that some beneficiaries in the presentstudy may have required only 1-time prescription fills for thetreatment of an acute condition, and, as such, did not representgood mail-order candidates. Under these circumstances, use ofthe local community pharmacy would likely have been the mostexpeditious source for the needed medication. Our findingsrevealed, however, that approximately 75% (n =108,379) ofstudy subjects who obtained 6 or more unique medicationsduring the study period did not use the mail-order pharmacy.A prior study on the age 65+ TRICARE beneficiary populationfound that maintenance medications dominated the medicationlists of TRICARE beneficiaries, and treatments for cardiovascu-lar disease, high blood pressure, diabetes, and arthritis toppedthe list of most commonly used medications.18 These beneficia-ries represent the ideal target population for DoD’s migrationinitiative for the transfer of prescription fills from communityand military pharmacies to TMOP.

LimitationsThe first limitation is the absence of important subjectiveinformation regarding beneficiary decision making that drivestheir pharmacy use patterns. More study is needed to investi-gate beneficiaries’ perceptions of and attitudes toward use ofthe mail-order pharmacy that ultimately must be addressedto achieve the desired migration of workload out of militarypharmacies. Survey-based studies investigating these issues arecurrently underway.

Second, our reliance on prescription fill data for our studymay present other limitations. Our use of GCNs to count medi-cations may have resulted in an overestime of medicationsused during the study period when beneficiaries filled multipleprescriptions that differed in strength, dosage form, or route ofadministration. It is also likely that some beneficiaries obtainedadditional medications not captured in our dataset, includingthose dispensed outside the 90-day study period or as part ofa hospitalization. The study dataset would also not capture filldata for beneficiaries who used other health insurance (withoutusing TRICARE as a second payer) or no insurance to pay for

their medication. Third, since our study sample was not drawnrandomly from the age 65+ DoD health care beneficiary popula-tion, our findings may not be generalizable to the beneficiarieswho resided in nontarget states.

nn ConclusionIf DoD intends to succeed in transferring more of the work-load associated with providing pharmacy services to TMOPfrom military and community pharmacies, it will need toaddress the lack of significant financial or other incentives forbeneficiaries to use mail order for maintenance medications.

Acknowledgments

The authors thank Dr. Richard Bannick and Ms. Amii Kress, Center forHealth Care Management Studies, for their assistance with the interpretationof the study dataset and Lt. Col. Thomas A. Bacon, DoD Pharmacy Program/OASD(HA)/TMA, for his review and input regarding this manuscript.

dIsclosUResThis research was funded solely by the Department of Defense. Authors AndreaLinton, Mathew Garber, Nancy K. Fagan, and Michael Peterson are employedby the Department of Defense and hold no affiliation with organizations thatmay incur a financial benefit as a result of this work being published.

Author Andrea Linton served as principal author of this study. Studyconcept and design were contributed by Linton, Nancy Fagan, and MichealPeterson. Data collection was the work of Linton, Fagan, and Peterson; data in-terpretation was primarily the work of Linton, with input from Mathew Garber.Writing of the manuscript and its revision was primarily the work of Linton,with input from Garber, Fagan, and Peterson.

RefeRences

1. Teagarden JR, Nagle B, Aubert RE, Wasdyke C, Courtney P, Epstein RS.Dispensing error rate in a highly automated mail-service pharmacy practice.Pharmacotherapy. 2005;25(11):1629-35.

2. Xu KT. Choice of and overall satisfaction with pharmacies among acommunity-dwelling elderly population. Med Care. 2002;40(12):1283-93.

3. Johnson JA, Coons SJ, Hays RD, Sabers D, Jones R, Langley PC. A compari-son of satisfaction with mail versus traditional pharmacy services. J Manag CarePharm. 1997;3(3):327-37. Available at: http://www.amcp.org/data/jmcp/research_v3_327-337.pdf.

4. Motheral BR, Heinle SM. Predictors of satisfaction of health plan memberswith prescription drug benefits. Am J Health Syst Pharm. 2004;61(10):1007-14.

AndreA Linton, MS, is a senior research associate, office of theAssistant Secretary of defense, Health Affairs (oASd[HA]), triCAreManagement Activity (tMA), Health Programs Analysis and evaluation(HPA&e); MAtHew GArber, Phd, is deputy director, dod PharmacyPrograms, oASd(HA)/tMA; nAnCy K. FAGAn, dVM, Phd, directorof epidemiology, oASd(HA)/tMA (HPA&e); MiCHAeL PeterSon,dVM, drPH, is director, HPA&e, oASd(HA).

AutHor CorreSPondenCe: Andrea Linton, Senior researchAssociate, office of the Assistant Secretary of defense, Health Affairs,triCAre Management Activity, Health Programs Analysis andevaluation, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041.tel.: (202) 207-5833; Fax: (703) 681-3682e-mail: [email protected]

Authors



5. Birtcher KK, Shepherd MD. Users’ perceptions of mail-service pharmacy.Am Pharm. 1992:NS32(12):35-41.

6. Office of the Assistant Secretary of Defense (Health Affairs) and theTRICARE Management Activity. TRICARE prescriptions homepage. Availableat: http://www.tricare.osd.mil/pharmacy/default.cfm. Accessed April 27, 2005.

7. Stergachis A, Maine LL, Brown L. The 2001 National Pharmacy ConsumerSurvey. J Am Pharm Assoc (Wash). 2002;42(4):568-76.

8. Lipowski EE. How consumers choose a pharmacy. Am Pharm. 1993;NS33(suppl 12):S14-S17.

9. Cox ER, Henderson RR. Prescription use behavior among Medicare beneficia-ries with capped prescription benefits. J Manag Care Pharm. 2002;8(5):360-64.Available at: http://www.amcp.org/data/jmcp/Research-360-364.pdf.

10. Spence MM, Hui R, Chan J. Cost reduction strategies used by elderlypatients with chronic obstructive pulmonary disease to cope with a generic-only pharmacy benefit. J Manag Care Pharm. 2006;12(5):377-82. Available at:http://www.amcp.org/data/jmcp/research_377-382.pdf.

11. Motheral B, Cox ER, Mager D, Henderson R, Martinez R. Express Scriptsprescription drug atlas. Available at: http://www.express-scripts.com/ourcompany/news/outcomesresearch/prescriptiondrugatlas/entireStudy.pdf.Accessed July 2, 2007.

12. Schommer JC, Mott DA, Hansen RA, Cline RR. Selected characteristics ofsenior citizens’ prescription drug payment and procurement in 1998 and 2001.

J Manag Care Pharm. 2003;9(5):408-15. Available at: http://www.amcp.org/data/jmcp/Research-408-415.pdf.

13. Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, FrankRG. The effect of incentive-based formularies on prescription drug utilizationand spending. n engl J Med. 2003;349(23):2224-32.

14. Rector TS, Finch MD, Danzon PM, Pauly MV, Manda BS. Effect of tieredprescription copayments on the use of preferred brand medications. Med Care.2003;41(3):398-406.

15. Thomas CP, Wallack SS, Lee S, Ritter GA. Impact of health plan design andmanagement on retirees’ prescription drug use and spending, 2001. Health Aff.December 4, 2002. Available at: http://content.healthaffairs.org/cgi/reprint/hlthaff.w2.408v1. Accessed August 6, 2007.

16. O’Malley AJ, Frank RG, Kaddis A, Rothenberg BM, McNeil BJ. Impact ofalternative interventions on changes in generic dispensing rates. Health Servres. 2006;41(5):1876-94.

17. Henry J. Kaiser Family Foundation. Prescription drug trends, June 2006.Available at: http://www.kff.org/rxdrugs/upload/3057-05.pdf. Accessed July 3,2007.

18. Linton A, Garber M, Fagan NK, Peterson MR. Examination of multiplemedication use among TRICARE beneficiaries aged 65 years and older.J Manag Care Pharm. 2007;13(2):155-62. Available at: http://www.amcp.org/data/jmcp/p155-62.pdf.


nn Reapplication Requirements for Prescription Assistance Program MischaracterizedTo the Editor:In the article by Clay et al. (“Costs to Physician Offices of Providing Medications to Medically Indigent Patients Via Phar-maceutical Manufacturer Prescription Assistance Programs”) in the July/August 2007 issue of JMCP, one of our company’s patient assistance programs is identified as requiring 4 applica-tions per year for a patient on a chronic medication.1 The authors state: “It is important to note that a PAP that requires 4 applications per year does not simply require completing the ‘once-annual’ application and submitting it 4 times. Instead, it involves collecting updated information from the patient (Table 2) and repeating the entire process 3 more times.” This statement is absolutely not correct for Schering-Plough’s SP-Cares program. The SP-Cares program only requires 1 completed applica-tion each year that must be signed by both the patient and physician and which must be accompanied by the required proof of the patient’s income. Once a patient is approved, up to a 3-month supply of the approved medications is shipped to the physician’s office for the physician to dispense to the patient. If the physician believes that the patient needs an additional 3-month supply of medications, then the physician merely needs to complete a simple re-order form and fax it into the program. The re-order form contains essentially the same infor-mation as a standard prescription–requiring only information on the identity of the patient and the prescriber, the medications being requested (along with dosage), and a signature from the prescriber. The patient does not need to sign the re-order form, nor is any income information required. We believe that it is in the best interest of patients to be in close communication with their physicians regarding use of these medications. For example, physicians may want to adjust the dosing of the medications or, in some instances, discontinue them. Having a program with 3-month checks in it allows for that determination to be deliberately addressed, while keeping the paperwork required at the physician’s office at a level similar to that of a simple prescription refill. Our company’s program was inaccurately characterized in the aforementioned article. We would appreciate your accepting this letter as a correction to that article.

Kathy ZoncaDirector, Patient Access & Advocacy

Schering-Plough CorporationKenilworth, NJ

[email protected]

Letters

RefeRences

1. Clay P, Vaught E, Glaros A, Mangum S, Hansen D, Lindsey CC. Costs to physician offices of providing medications to medically indigent patients via pharmaceutical manufacturer prescription assistance programs. J Manag Care Pharm. 2007;13(6):506-14. Available at: http://www.amcp.org/data/jmcp/ pages%20506-514.pdf.

The Authors Respond:We appreciate the thorough review of our article by Schering-Plough Corporation as represented by Zonca.1 She asserts that we have mischaracterized “SP-CARES” paperwork requirements while at the same time promoting that quarterly follow-up visits to obtain refills for the provided medications is “in the best interest of patients.” On the point of mischaracterization, she is correct in her assertion that per the instructions on the “SP-CARES Patient Assistance Program Re-Order Request” form that is available online, there is not a specific request for those completing the form to resubmit the necessary materials as per the original qualifying application.2 Indeed, at the top of this form is the statement (in large, bold-type font), “To be eligible to receive a re-order of product, the below-named patient must have been determined eligible and approved for participation in the Program within the past nine (9) months.” Alas, that is not the only statement on the form. A close scrutiny of the text in smaller font found in the section just above where the physi-cian is required to sign shows the following statements: “To the best of my knowledge, I (the physician signing the form) attest that the information provided in the above-named patient’s applica-tion for the Program, including his or her financial insurance information, has not changed.… The patient does not have and is not eligible for prescription drug coverage (including private insurance, Medicare Supplemental, Medicaid, state assistance programs, etc.).… I agree to allow Schering, or its authorized agent(s) to review the medical, financial and insurance records for this patient at any time for the purpose of verifying the patient’s eligibility status for the Program…” While Hippocrates may have instilled in physicians the notion of “First, do no harm,” the US legal system’s impact on physician’s considerations to avoid the appearance of fraud and unethical behavior is large.3,4 The last statement included above provides permission for inspection, with possible subsequent criminal and civil litigation against a physician should eligibility be lost in the interim between the initial application and re-order. Therefore, it is incumbent on the physician to assure that the financial qualifiers for the patient when he or she initially applied to the program have not changed. Provision by the patient of updated fiduciary materials to the physician’s office is the only way in which the physician can attest to this fact. This due diligence on the part of the physician is no different than what is expected of a physician if an initial round of chemotherapy had been administered and verification for a second round was required.


With respect to the point that quarterly physician appoint-ments are “in the best interest of patients,” we do not believe that a pharmaceutical company should attempt to dictate clinical practice through its prescription assistance program. Zonca claims that Schering-Plough’s application forms are designed to “deliberately” determine when patients return for follow-up. We refer Zonca to the most recent recommendations from the National Heart, Lung, and Blood Institute for its recommenda-tions pertaining to the monitoring frequency for people with asthma (Asmanex Twisthaler is included on the SP-CARES re-order form and is approved for the maintenance treatment of asthma5): “The Expert Panel recommends that the frequency of visits to a clinician for review of asthma control is a matter of clinical judgment; in general, patients who have intermittent or mild persistent asthma that has been under control for at least 3 months should be seen by a clinician about every 6 months.” 6

If Zonca or others would like to argue this point, we suggest that they take up the matter with the NHLBI.

Patrick Clay, PharmDDirector of Clinical Research and

Associate Professor of MedicineKansas City University of Medicine and Biosciences

[email protected]

Cameron C. Lindsey, PharmD, BC-ADMAssociate Professor of Pharmacy Practice

University of Missouri-Kansas City

Stacy Mangum, PharmDDirector of Pharmacy

Missouri Southern Healthcare, Dexter

DisclosuresThe authors disclose no potential bias or conflict of interest relating to their original research. Portion of the original research article were presented as a poster, “Cost of Providing Medications Via Prescription Assistance Programs to Medically Indigent Patients,” at a student session at the 49th Annual American Osteopathic Medical Association Meeting October 25, 2005, in Orlando, FL.

references1. Clay P, Vaught E, Glaros A, Mangum S, Hansen D, Lindsey CC. Costs to physician offices of providing medications to medically indigent patients via pharmaceutical manufacturer prescription assistance programs. J Manag Care Pharm. 2007;13(6):506-14. Available at: http://www.amcp.org/data/jmcp/ pages%20506-514.pdf.

2. Schering PAP Re-Order Form 11-04; Form MC2176 1/07. Accessed on September 9, 2007. Available at: http://www.schering-plough.com/pdf/ physician_reorder.pdf.

3. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients: between a rock and a hard place. JAMA. 2000:283(14):1858-65.

4. Rosenbaum S. The impact of United State law on medicine as a profession. JAMA. 2003:289(12):1546-56.

5. Asmanex Twisthaler. Package insert. Schering Corporation, Kenilworth, New Jersey 07033. July 2005. Available at: http://www.spfiles.com/piasmanex.pdf. Accessed on: September 9, 2007.

6. Third Expert Panel on the Diagnosis and Management of Asthma. Expert Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/04_sec3_comp.pdf. Accessed on September 9, 2007.

Letters

letters to the editorJMCP welcomes letters that serve to clarify subjects published in previous issues of the Journal or regarding subject matter of interest to managed care pharmacists. Letters in JMCP are not peer reviewed but are subjected to editorial review. Letters should be prepared in a word processing program, preferably Micro-soft Word, and submitted electronically at jmcp.msubmit.net. See www.amcp.org for details.


The following poster presentations have been preparedfor the Academy of Managed Care Pharmacy’s 2007Educational Conference, October 24-27, 2007, in Boston,

Massachusetts. Poster presentations are selected by the ProgramPlanning and Development Committee from proposals that aresubmitted to AMCP. Authors of posters are responsible for theaccuracy and completeness of the data presented in the postersand in the abstracts published here.

For more information about the studies described below,please contact the corresponding authors, indicated by anasterisk (*), whose addresses are listed in full. The names ofindividuals who are scheduled to present at the meeting areunderlined.

ADHERENCE TO ACC/AHA GUIDELINES FORMYOCARDIAL INFARCTION AND HEART FAILURE ANDPERSISTENCE WITH ACE INHIBITOR OR ARB TREATMENTHess G,* Preblick R, Curry A, Plauschinat C. Surveillance Data Inc.,220 West Germantown Pike, Suite 140, Plymouth Meeting, PA 19462;[email protected], (610) 834-0800, ext. 1711

BACKGROUND: American College of Cardiology (ACC)/AmericanHealth Association (AHA) guidelines recommend the use ofangiotensin-converting enzyme inhibitors (ACEIs) or angio-tensin-receptor blockers (ARBs) following an acute myocardialinfarction (MI) and/or heart failure (HF).PURPOse: To analyze prescribing and persistence with ACEIor ARB therapy for patients following acute MI and/or heartfailure.MethODs: Approximately 40,000 electronic records were ana-lyzed covering January 2003–December 2005 for patients witha hospital discharge diagnosis of acute MI and/or heart failure.Patients were matched to the out-patient setting, including pre-scription claims. For up to 12 months following discharge, eachpatient was observed for an ACEI or ARB or neither. Switchingand combination therapies within and between classes werecategorized as still on therapy. Based on the dispensed drug(s)and days supply, patients were analyzed for their monthly per-sistency and refill gaps.ResUlts: In the study of 39,914 patients, there were 25,145(≈ 63%) who received an ACEI and/or an ARB while 14,769(≈ 37%) received no ACEI or ARB for up to 12 months after theindex event (acute MI or HF). At the start of therapy, patientshad an average gap of 12 days in between their first and secondfilled prescription, while patients still persistent on medicationat the end of the 12-month follow-up had only a 1-day gap intherapy. On average, only 22% of patients were still persistent12 months after the start of therapy. Statistically, each of thecomparative findings was significant (P < 0.05).

CONClUsiON: Adherence to the guidelines recommending ACEIor ARB therapy was low. Persistence was universally low forpatients on therapy, regardless of receiving an ACEI or an ARB.Educational programs and incentives to increase physician and/or patient awareness and adherence to the guidelines shouldbe considered, particularly for patients newly discharged andinitiating therapy.

ADHERENCE TO DISEASE-MODIFYINGTHERAPIES IN PATIENTS WITH MULTIPLE SCLEROSISMaxwell RA,* Treadaway K, Brannon K, Morrison A, Remington G,Racke M, Hawker K, Olek M, Frohman E. Biogen Idec, 106 Marshall Dr.,Pittsburgh, PA 15235; [email protected], (412) 727-7168

BACKGROUND: Optimal treatment with disease-modifying ther-apy (DMT) in patients with multiple sclerosis (MS) is con-tingent upon consistent use. Lack of adherence to prescribedmedication is a known problem in chronic disease.OBjeCtives: This retrospective study was undertaken to deter-mine which factors are most critical in affecting strict adherenceto DMT injection schedules.MethODs: Participants were recruited from 17 academic andcommunity sites across the country for this Web-based sur-vey. Patients completed a survey that included the MultipleSclerosis Quality of Life Measurement (MSQOL-54), the HerthHope Index, the Beck Depression Index-Fast Screen for MedicalPatients, a quantitative analysis of drug compliance, and ques-tions related to health care setting and support. The surveyswere administered at baseline, 1 month, and 2 months.ResUlts: Seven hundred and ninety-eight patients receiving 1 of4 DMTs (intramuscular interferon beta-1a, subcutaneous inter-feron beta-1a, interferon beta-1b, or glatiramer acetate) enrolledin the study and 708 completed all 3 waves. Noncompliance(missing at least 1 DMT injection within 4 weeks prior to the sur-vey) decreased slightly across the 3 waves (39%, 37%, 36%). Thereason most often reported for noncompliance was forgetfulness(58%). Other reasons cited included not feeling like taking theinjection (22%), tired of taking injections (16%), fatigue (12%),and pain at the injection site (7%). The need for more frequentinjections was associated with lower rates of compliance (dailyinjections 49% vs. weekly injections 79%). Nonadherent patientshad significantly more injection site reactions than did adherentpatients. On the MSQOL-54, adherent patients had significantlyhigher scores on most critical parameters of physical and emo-tional well-being compared with nonadherent patients.CONClUsiONs: Noncompliance with prescribed medication wasa substantial problem in this study. Compared with nonadher-ent patients, adherent patients had a significantly higher QOLscores. The results of this study provide insight into factors

Abstracts From Professional Poster Presentationsat AMCP’s 2007 Educational Conference

ABSTRACTS


that should be considered when trying to improve or maintainadherence with therapy in patients with MS.

ASSESSMENT OF GLAUCOMA MEDICATION SAFETYPROFILE AND PATIENT REPORTED OUTCOMES (PROS)FROM AN INTERNET-BASED PATIENT REGISTRYWalt JG,* Chiang TH, Tran N. Allergan, Inc., 2525 Dupont Dr., Irvine,CA 92612; [email protected], (714) 246-6719

iNtRODUCtiON: Prostaglandin analogs are generally the mostpotent class of intraocular-pressure (IOP)-reducing drugs and areoften prescribed as first-line treatment of glaucoma. High potencyis sometimes associated with side effects. Studies have indicatedthat there may be some differences in safety among the drugs inthis class. The purpose of this analysis was to compare the safetyprofile of bimatoprost, latanoprost, and travoprost as first- orsecond-line monotherapy during its first 3 months of treatmentand patient satisfaction with their respective treatment.MethODs: In this 1-year prospective, naturalistic, randomized,investigator-masked, observational study, 1,099 patients withprimary open-angle glaucoma (POAG) or ocular hypertension(OHT) were enrolled and treated with bimatoprost, latanoprost,or travoprost. Expected adverse events such as hyperemia andunexpected adverse events data and patient-reported outcomes(PROs) were measured to help evaluate safety and patient satis-faction with their randomized therapy.ResUlts: Of the 1,099 patients from 41 centers enrolled, 357returned for a follow-up visit within the first 3 months oftreatment. Among group differences in expected (P=0.0711)and unexpected adverse events rates (P=0.3777) were similar.Occurrences of hyperemia were also similar for bimatoprost,travoprost, and latanoprost; 56.2%, 54.3%, and 47.5%, respec-tively (P=0.01997). Patients’ willingness to continue with theirstudy treatment was similar for all treatment groups; bimatoprost(97.4%), travoprost (94.8%), and latanoprost (94.1%; P=0.1047).CONClUsiON: The glaucoma medications in the prostaglandinanalog class are similar in its safety profile in the first 3 monthsafter therapy initiation. Patients’ willingness to continue withtheir treatment was high for all 3 medications in the prosta-glandin class.

ASSESSMENT OF WORk ABSENCESASSOCIATED WITH INSOMNIAKleinman NL, Brook RA,* Melkonian AK, Doan JF, Baran RW. TheJeSTARx Group, 18 Hirth Dr., Newfoundland, NJ 07435; (973) 208-8621,[email protected]

BACKGROUND: Chronic insomnia affects more than 10% of theadult population and is associated with significant direct costsand even more pronounced indirect costs.OBjeCtive: To assess the annual incidence of work absencesassociated with insomnia in an employed population.

MethODs: Retrospective analysis was conducted using the HumanCapital Management Services Reference Database (employee datafrom 2001-2006 for multiple U.S.-based employers). Medicaland payroll records were collected, as well as information onwork absences and employee demographics. Employees wereidentified with insomnia based on history of hypnotic drug useor diagnosis of a sleep disorder (International Classification ofDiseases). Diagnostic codes for insomnia included: 307.41 (tran-sient disorder of initiating or maintaining sleep), 307.42 (persis-tent disorder of initiating or maintaining sleep), 307.49 (subjec-tive insomnia), and 780.52 (insomnia). Controls were employeeswithout a history of hypnotic drug exposure or insomnia diag-nosis. In this analysis, the annual incidence of work absences foremployees in the insomnia group and those in the control groupwere compared. The insomnia group index date was defined asfirst diagnosis date or hypnotic claim, with the average insom-nia group index date used for the control group. Incidence ofwork absence differences between insomnia and control groupswere determined using regression modeling controlling for age,job tenure, gender, salary, geographic region, comorbid mentaldisorders, and the Charlson Comorbidity Index.ResUlts: Data were collected for more than 137,000 employ-ees. Employees in the insomnia group had significantly moreannual mean incremental absence days compared to the controlgroup (additional 5.01 days). The additional days consisted ofsick leave (47.4%, 2.37 days, P<0.0001), short-term disability(38.5%, 1.93 days, P<0.0001), long-term disability (11.0%, 0.55days, P<0.0002), and worker’s compensation (3.1%, 0.15 days,P<0.003).CONClUsiONs: Employees with insomnia incur more than twiceas many annual paid work absence days than employees with-out insomnia.

CHARACTERISTICS OF AND TRENDS IN THE LATE-STAGE BIOPHARMACEUTICAL PIPELINE: 2003 TO 2006Nagle PC, Nicita CA, Gerdes LA, Schmeichel CJ.* Centocor, Inc.163 Edenwood #205, Ann Arbor, MI 48103; [email protected],(734) 657-1596

OBjeCtive: To characterize biopharmaceuticals in late-stagedevelopment in the United States as of May 2006 and to com-pare these results to earlier analyses.MethODs: Biopharmaceuticals in late-stage U.S. development(that had completed phase 2 or higher) were identified andcharacterized through reviews of literature, 5 drug-develop-ment databases, a clinical trial database, and through telephoneinquiries with manufacturers. These results were compared tofindings from April 2003.ResUlts: Biopharmaceutical was previously defined as “anybiology-based therapeutic that structurally mimics compoundsfound within the body.” This includes recombinant proteins,monoclonal and polyclonal antibodies, peptides, antisense



oligonucleotides, therapeutic genes, and certain therapeuticvaccines. As of May 2006, there were 111 unique biopharma-ceuticals in late-stage development for 190 indications in 38disease categories, affecting at least 33 distinct physician spe-cialties. Cancer agents are the most common, with 43 agents(39%) targeting 83 indications (44%). Approximately 90% ofthe biopharmaceuticals will require administration via injec-tion or infusion, more than 70% will require administration bya health care provider, and nearly 60% will be administered inambulatory care settings. Approximately 85% of physician spe-cialties (28 out of 33) will be affected by health care provider-administered biopharmaceuticals. Excluding cancer-relatedbiopharmaceuticals, 54% of biopharmaceuticals and 61% ofindications require chronic administration. We calculate thatup to 87 biopharmaceuticals targeting 156 indications may beapproved within the next 4 years (including secondary approv-als). The number of agents and indications in the pipeline hasexpanded since 2003 (102 biopharmaceuticals, 156 indica-tions) whereas the characteristics of the pipeline have remainedrelatively constant.CONClUsiONs: The continued growth of the U.S. biopharma-ceutical pipeline has increasingly significant implications forthird-party payers across a wide range of clinical, administra-tive, delivery, and economic issues.

THE CLINICAL OUTCOMES AND COST IMPACTASSOCIATED WITH AN HPV 16/18 CERVICAL CANCERCANDIDATE VACCINE BASED ON A HEALTH ECONOMIC MODELTaylor DCA,* Kruzikas DT, Thompson D, Pandya A, Iskandar R, GilmoreK, Weinstein MC. i3 Innovus, 10 Cabot Rd., Suite 304, Medford, MA,02155; [email protected], (781) 518-4033

BACKGROUND: The clinical and cost impact of vaccination inthe prevention of human papillomavirus (HPV)-related cervicalcomplications in the United States was evaluated.MethODs: A natural history model simulated the theoreti-cal lifetime impact of vaccination, combined with screening,targeting a cohort of 2.0 million 12-year-old U.S. females. Astrategy of using a vaccine against HPV 16/18 infection withcross-protection against HPV 45 and 31 was compared withreceiving no vaccination. This vaccination strategy was evalu-ated at 100% and 70% coverage, with vaccination costs of $360per 3-dose series. Model inputs were based on clinical trial dataand published literature. Outcome measures included cervicalintraepithelial neoplasia (CIN) cases, cervical cancer cases,cervical cancer deaths, and cervical-disease medical costs.Discount rates of 3% were applied to costs.ResUlts: At 100% coverage, vaccination was estimated toreduce the incidence of mild dysplasia (CIN1), moderate dys-plasia (CIN2), and severe dysplasia (CIN3), cervical cancer andrelated mortality by 32%, 34%, 39%, 78%, and 79%, respec-tively, compared with screening alone. At 70% coverage, vac-

cination was estimated to reduce cervical cancer incidence bymore than 50%. At full vaccination coverage, the numbers offemales needed to be vaccinated to prevent one case of CIN1,CIN2, CIN3, and cervical cancer were 21, 30, 24, and 177,respectively. Ranging coverage from 70% to 100%, vaccinationresulted in direct medical cost offsets of $296 to $423 milliondue to reduced incidence and related treatment of precancerouslesions and cervical cancer.CONClUsiONs: In our model, compared with current screen-ing practices alone, an HPV 16/18 cervical cancer candidatevaccine with cross-protection, combined with screening, mayprovide significant reductions in HPV-related cervical compli-cations and associated medical care costs. When data confirmsthe profile projected, this model indicates vaccination has thepotential to prevent nearly 80% of cervical cancer cases, and forevery 30 females vaccinated, one case of CIN1, CIN2, and CIN3may be prevented.FiNANCiAl sUPPORt: GlaxoSmithKline provided funding forthis research.

COMPARING MEDICAL UTILIzATION ANDExPENDITURES BETWEEN SWITCHERS ANDNONSWITCHERS FOR TUMOR NECROSIS FACTORINHIBITORS IN THE TREATMENT OF RHEUMATOID ARTHRITISAhmad BN, Nair KV,* Tang B, Van Den Bos J, Zhang V, Naim A, RahmanM. Centocor, Inc., 800 Ridgeview Dr., H-2-3, Horsham, PA 19044;[email protected], (215) 325-4237

OBjeCtive: To evaluate the impact of switching among anti-tumor necrosis factors (anti-TNF) on rheumatoid arthritis (RA)-related medical utilization and expenditures.MethODs: A retrospective study using the Medstat MarketScandatabase was conducted to compare RA-related utilization andhealth care costs among RA patients who switched from one anti-TNF to another with those who did not. Eligibility criteria included:(a) a diagnosis of RA International Classification for Diseases, NinthRevision ([ICD-9] code 714.xx), (b) a minimum of 3 administra-tions of infliximab or 2 continuous prescriptions for etanercept oradalimumab between the years 1999 and 2005, (c) no anti-TNF usewithin 6 months prior to the index date, and (d) continuous enroll-ment for 12 months after the index date. RA-related utilizationand health care expenditures were compared between “switchers”(patients who switched to another anti-TNF during the study peri-od) and “nonswitchers” (those who stayed on their index drug).ResUlts: Less than 10% of patients switched within the firstyear following their index date. Of those who switched, themajority switched only once (87.5% in commercial and 89.5%in Medicare). The unadjusted mean health care expendituresper member per month (PMPM) were lower for nonswitcherscompared with switchers for commercial (34.7%) and Medicare(34.3%) patients. Also, switchers in the commercial popula-tion had an average of 1.23 outpatient visits, 1.51 laboratory



services, 0.07 outpatient surgeries and 3.42 scripts more PMPMthan nonswitchers. We observed similar trends in the Medicarepopulation and all differences were statistically significant.However, the average length of stay was higher for nonswitchers(4.17 days) compared with switchers (3.88 days) in the commer-cial population. Switchers were sicker (higher risk scores) thannonswitchers in both commercial and Medicare populations.CONClUsiONs: A minority of patients taking anti-TNF for RAswitched to another anti-TNF during the first year of treatment.Those who switched had higher health care expenditures andutilization for most medical services.

CONTENT ANALYSIS OF FDA WARNINGLETTERS TO MANUFACTURERS CONCERNINGPROMOTIONAL VIOLATIONSParekh R, Rane P, Kamal KM,* Desselle SP.* Duquesne University, Schoolof Pharmacy, 600 Forbes Ave., Pittsburgh, PA 15282; [email protected],(412) 580-4938

OBjeCtive: To critically evaluate the content of letters of noticeand warning letters from the U.S. Food and Drug Administration(FDA) to manufacturers for promotional violations.MethODs: Two judges formally trained in content analysisprocedures critically evaluated the content of publicly availableletters from 2000 to 2006. Judges’ inferences were coded intobinary response sets for each variable. Disagreements amongjudges were adjudicated by a third researcher. Inter-rater reli-abilities among the judges were determined through kappastatistics. Chi-square statistics were used to discern differencesin violation types by medium.ResUlts: The 249 letters described 739 violations from 107manufacturers, with greater numbers of letters seen in earlieryears of the study period. Letters from latter years were gen-erally more detailed and descriptive than those from earlieryears. Media most frequently cited in letters were print (n=72), “sales aids,” (n=45), and the Internet (n=40). Violationswere most frequently related to lack of fair balance (n=128),misleading claims of efficacy (n=101), and omission of riskinformation (n=89). Inter-rater reliabilities among the 2 judgeswere exceptional, ranging from 0.86 to 1.00. Chi-square analy-ses revealed that various types of violations were more preva-lent in certain media. For example, while lack of fair balancewas noted in 54.8% of direct-to-consumer advertising viola-tions, it was observed only in 22.2% of conference presentationviolations; conversely, promotion of unapproved drugs wascited in nearly one third of conference presentation violations,but relatively absent in all other types of marketing.CONClUsiONs: The marketing of prescription drugs has a sig-nificant impact on the medication use process. Managed carepolicymakers and pharmacists should remain abreast of pro-motional strategies and claims, particularly those deemed prob-lematic by the FDA, which may spur requests for additional

information, prescriptions, and/or formulary status changes forthe drugs promoted.

COST OF POST-DISCHARGE ANTICOAGULATIONUSING ORAL VERSUS INJECTABLE AGENTSFOLLOWING MAJOR ORTHOPAEDIC SURGERY (MOS)Shorr A, Horblyuk R,* Happe L, Farrelly E. GlaxoSmithKline, 200 N.16th St. Mailstop FP1280, Philadelphia, PA 19102; [email protected], (215) 751-6535

iNtRODUCtiON: Thromboembolic events following major ortho-paedic surgery (MOS) have substantial clinical and economicconsequences. Inpatient anticoagulation following these proce-dures is common, yet extended anticoagulation in an outpatientsetting is variable. Furthermore, limited data exist differentiat-ing outcomes based of the form of extended anticoagulation(oral vs. injectable). The objective of this study was to assesscosts and clinical outcomes in MOS patients receiving extendedprophylaxis with either oral or injectable anticoagulants post-discharge from the third-party payer perspective.MethODs: We completed a retrospective matched cohortanalysis utilizing data from the PharMetrics dataset fromMarch 1, 2002 to September 30, 2005. Patients with totalhip or knee arthroplasty or hip fracture surgery who post-discharge received an injectable anticoagulant (dalteparin,enoxaparin, or fondaparinux) were matched 1:1 to warfa-rin users based on demographics (gender, age) and clinicalcharacteristics (prior thrombotic event, Charlson comorbid-ity score). Average total 6-month costs (medical and phar-macy) were calculated for each cohort. Occurrence of venousthromboembolism (VTE) and major bleeds were identifiedby International Classification of Diseases, Ninth Revision codesduring the 90 days post-discharge.ResUlts: Six thousand three hundred and sixty-two patientsreceiving injectable anticoagulation were matched 1:1 to war-farin users. Patient mean age was (mean ± SD) 55.6±8.6,and 56% were female. Average total 6-month costs were sig-nificantly lower for the injectable vs. oral cohort ($16,424 vs.$18,298; P=0.0003). Higher pharmacy costs associated withinjectable anticoagulation were offset by lower total medicalcosts (pharmacy: oral=$1,671 vs. injectable=$2,056; medical:oral=$16,627 vs. injectable=$14,368). Patients treated withwarfarin were 20% more likely to experience a VTE than thosetreated with an injectable anticoagulant (7.4% vs. 6.3%; oddsratio= 1.2; 95% confidence interval, 1.0-1.4). No significantbetween-group differences were observed for bleeding events(oral=0.28%, injectable= 0.31%, P=0.7453).CONClUsiONs: The risk of thromboembolic events followingMOS continue into the outpatient setting post-discharge. Despitetheir higher acquisition costs, extended prophylaxis with inject-able anticoagulants may offer clinical benefits over warfarin andhave potential to result in cost savings for health plans.



COST-EFFECTIVENESS OF ALISkIREN, A DIRECTRENIN INHIBITOR, COMPARED WITH CURRENTANTIHYPERTENSIVE MEDICATIONS FOR PATIENTSWITH MILD-TO-MODERATE HYPERTENSIONLau H,* Duff S, Gricar J, Reyes E, Sung J, Davis P, Griffiths R. NovartisPharmaceuticals Corporation, 59 Rte. 10, 405/2010B, East Hanover, NJ07936; [email protected], (862) 778-8883

BACKGROUND: Direct renin inhibitors (DRIs) are a new classof antihypertensive medications.OBjeCtive: To evaluate the cost-effectiveness of the DRIaliskiren versus the angiotensin receptor blocker losartanand angiotensin converting enzyme-inhibitor ramipril formild-to-moderate hypertension from a third-party payerperspective.MethODs: Clinical data from prospective clinical trials ofaliskiren and reported clinical efficacies of comparators wereused to estimate cardiovascular events and deaths based onsystolic blood pressure (SBP) reductions using Framinghamrisk equations. Patients were assumed to be 54 years of age,baseline SBP=153.3 mm mercury (Hg), and baseline totalcholesterol to high-density lipoprotein ratio=4.7. EstimatedSBP reductions for aliskiren, losartan, and ramipril were 11.2mm Hg, 10.5 mm Hg, and 6.0 mm Hg, respectively. Expectedsurvival benefit and costs over 1-, 5-, and 10-year time-hori-zons were computed based on a decision-analysis model. Allvalues were discounted at 3% annually.

Incremental cost-effectiveness ratios (ICERs) were calcu-lated by dividing the differences in expected total costs bydifferences in expected survival (in life-years). Sensitivityanalyses focused on age and cardiovascular risk factors.

ResUlts: ICERs (based on 100,000 patients) exceeded$100,000 for 1- and 5-year time-horizons; however, they weremore favorable over 10 years. Patients who were older or hadcardiovascular risk factors had favorable ICERs.CONClUsiONs: Differences in cost-effectiveness outcomeswere observed depending on time horizons. ICERs were> $100,000 for 1- and 5-year time horizons, but older patientsand patients with cardiovascular risk factors had favorableICERs with aliskiren compared with losartan or ramipril at10 years. Results suggest that aliskiren would be cost-effec-tive for some patients with mild-to-moderate hypertensionover the long term.

THE COST OF TREATING END-STAGE RENAL DISEASEWITHIN A MANAGED CARE ORGANIzATIONDaniel G,* Gitlin M, McNeeley B, Kim, J, Mayne, TJ. HealthCore, Inc.,800 Delaware Ave., 5th Floor, Wilmington, DE 19801;[email protected], (302) 354-7607

BACKGROUND: Though a great deal is known about the costs oftreating end-stage renal disease (ESRD) from the Medicare per-spective, less is known about the costs to commercial managedcare organizations. These organizations cover the majority ofpatient costs before the 30-month roll over into Medicare.OBjeCtive: To evaluate the cost of treating ESRD from the com-mercial managed care perspective.MethODs: We analyzed inpatient, outpatient, and pharmacyclaims for all enrolled members of a national managed careorganization during 2 time periods: August 1, 2004-July 31,2005 (year 1) and August 1, 2005-July 31, 2006 (year 2).ESRD patients were defined as having ≥ 3 dialysis-related,or ≥ 1 ESRD-specific claim on separate days during each12-month period. Patients, treatments, and plan paid costswere identified using International Classification of Diseases,Ninth Revision diagnosis/procedure, Current ProceduralTerminology/Healthcare Common Procedures Coding Systemand Universal Billing 1992 codes, as well as Generic ProductIdentifier codes linked to National Drug Codes. Descriptivecosts and the most commonly observed diagnoses, services,and medications were assessed across inpatient, outpatient,and pharmacy settings.ResUlts: We identified 4,791 ESRD patients in year 1 and 4,611in year 2. Total average cost/patient was $58,094 (year 1) and$62,624 (year 2; Table 1). Per-member-per-month (PMPM) andper-patient-per-month (PPPM) costs were $11.23 per $4,841(year 1) and $11.13 per $5,157 (year 2). Among the top 20inpatient admission diagnoses, renal, cardiovascular, and respi-ratory were the most common. The most frequently prescribedmedications over both years included drugs used to treathypertension (16%), infections (10%), gastrointestinal or ulcer(9%), psychiatric disorders (7%), and pain (5%). Erythropoiesis-stimulating agents accounted for about 5% of total ESRD costsin year 1 ($280 PPPM) and year 2 ($264 PPPM).


TABLE Incremental Cost-EffectivenessRatios Over 10 Years

Aliskiren vs. Losartan Aliskiren vs Ramipril

CardiovascularRisk Factor Men Women Men Women

None $43,485 $72,110 $42,207 $70,688

Aged 65years

$16,713 $25,811 $16,027 $25,254

Smoker $18,574 $34,127 $17,871 $33,405

History ofcardiovasculardisease $21,470 $45,822 $20,707 $44,962

Diabetes $25,792 $31,250 $24,925 $30,566

Atrialfibrillation

$19,648 $16,575 $18,926 $16,231

Left ventricularhypertrophy $ 8,996 $19,584 $8,521 $19,109


CONClUsiONs: Total ESRD costs reported here are similar toMedicare ESRD cost data reported by United States Renal DataSystem (USRDS) ($58,000 per patient, USRDS 2004). Totalcosts, including patient copays, would produce higher overallsocietal costs. As with Medicare, the leading cost center forESRD patients is inpatient services.

COSTS AND OUTCOMES FOR MILD PERSISTENT ASTHMAPATIENTS ON ALTERNATIVE CONTROLLER THERAPIESColice GL,* Yu AP, Ivanova JI, Hsieh M, Birnbaum HB, Lage MJ, BrewsterC. Analysis Group, LLC, 111 Huntington Ave., 10th Floor, Boston, MA02199; [email protected], (617) 425-8000

BACKGROUND: The economic outcomes of initiating differentcontroller therapies in mild persistent asthma are not wellunderstood.OBjeCtives: To compare costs and patient outcomes measuredby hospitalizations and emergency room visits in mild per-sistent asthma patients initiating regular use of inhaled corti-costeroids (ICSs), ICS and long-acting b2-agonists (LABA), orleukotriene modifiers (LM).MethODs: Study patients, selected from a privately insuredclaims database (1999-2005), had at least 1 asthma diagno-sis; no diagnosis of chronic obstructive pulmonary disease;mild persistent asthma as defined by the 2005 HealthcareEffectiveness Data and Information Set, Leidy’s reliever andoral steroid methods, and the 2004 Global Initiative for Asthmaguidelines; and initiated regular use of ICS, ICS+LABA or LM.The index date was defined as the date of the first ICS, ICS+LABA, or LM prescription fill. Wilcoxon rank-sum tests wereused for descriptive pair-wise comparison of patient outcomesand costs in the 12 months after the index date. Multivariategeneralized linear models were used to compare costs adjustingfor patient characteristics.ResUlts: The final sample included 319 patients with regularuse of ICS, 414 patients with ICS+LABA, and 550 patientswith LM. There were no significant differences in patientoutcomes, as measured by hospitalizations and emergencyroom visits (all-cause as well as asthma-specific) among the3 cohorts. Total direct costs were significantly lower with ICSand LM compared with ICS+LABA (ICS: $3,971, P<0.01 com-pared with ICS+LABA; ICS+LABA: $4,733, P<0.01 comparedwith LM; LM: $4,148) and not significantly different between

ICS and LM. Asthma-related direct costs were the lowest withICS compared with both ICS + LABA and LM (ICS: $819,P< 0.01 compared with ICS+LABA, P<0.01 compared withLM; ICS+LABA: $1,094, P<0.01 compared with LM; LM:$869). Descriptive costs results were confirmed by the multi-variate analysis.CONClUsiON: Regular ICS use in mild persistent asthma wasassociated with lower total direct costs compared with ICS+LABA and the lowest asthma-related direct costs comparedwith ICS+LABA or LM, without any corresponding differencein patient outcomes.

COSTS AND RESOURCE UTILIzATION AMONG PATIENTSWITH PROGRESSION OF PRIMARY OPEN ANGLE GLAUCOMAWalt JG,* Chiang TH, Stern L, Doyle JJ, Berenson KL Allergan, Inc., 2525Dupont Dr., Irvine, CA 92612-1599; [email protected], (714) 246-6719

BACKGROUND: Glaucoma is a disease that, with progression, canlead to blindness. Mean deviation (MD) scores are used to mea-sure the degree of visual field loss in glaucoma patients. Whileworsening MD scores may not be noticeable to the patient, theymay be a factor in driving resource utilization and costs amongglaucoma patients.OBjeCtive: To develop a health economic model to measurethe costs and resources utilized for patients with progression ofglaucoma, as evidenced by worsening MD scores.MethODs: A health economic model was used to simulateglaucoma progression for a cohort of 600 patients over 4 yearsusing chart review data and published literature. Regressionanalyses of U.S. chart review data (N = 161, mean age of 66.3years, minimum follow-up of 4 years) were conducted tocalculate the expected number of ophthalmologist visits andexams, glaucoma medications and glaucoma surgeries forpatients with progression of glaucoma; these algorithms wereincorporated in the health economic model. Unit costs wereapplied to the resource utilization estimates to calculate theexpected 4-year pharmacy and medical costs of progression.The modeled patient data were also used to predict utilityscores based on a regression analysis of utility scores amongglaucoma patients and these algorithms were used to estimatethe change in quality-adjusted life-years (QALYs) over 4 yearsof glaucoma progression.ResUlts: The 4-year cost for the cohort was $3,957 per patient($598 in pharmacy costs and $3,359 in medical costs) with 2.96QALYs accumulated over 4 years.CONClUsiONs: Glaucoma progression is associated with a lossin quality of life and an increase in medical and pharmacyresource use with a corresponding increase in health care costs.It follows that slowing glaucoma progression will purport-edly delay the loss of quality of life and postpone the resultantincrease in health care costs.


YearInpatient

(Mean + SD)Outpatient(Mean + SD)

Pharmacy(Mean + SD)

Year 1 (n = 4,791)

Year 2 (n = 4,611)

$31,067 + $97,343 $24,221 + $40,302

$23,712 + $38,568$35,619 + $123,705

$2,806 + $4,637

$3,293 + $5,644

TABLE Treatment Costs for ESRD Patients


CONClUsiONs: Total ESRD costs reported here are similar toMedicare ESRD cost data reported by United States Renal DataSystem (USRDS) ($58,000 per patient, USRDS 2004). Totalcosts, including patient copays, would produce higher overallsocietal costs. As with Medicare, the leading cost center forESRD patients is inpatient services.

COSTS AND OUTCOMES FOR MILD PERSISTENT ASTHMAPATIENTS ON ALTERNATIVE CONTROLLER THERAPIESColice GL,* Yu AP, Ivanova JI, Hsieh M, Birnbaum HB, Lage MJ, BrewsterC. Analysis Group, LLC, 111 Huntington Ave., 10th Floor, Boston, MA02199; [email protected], (617) 425-8000

BACKGROUND: The economic outcomes of initiating differentcontroller therapies in mild persistent asthma are not wellunderstood.OBjeCtives: To compare costs and patient outcomes measuredby hospitalizations and emergency room visits in mild per-sistent asthma patients initiating regular use of inhaled corti-costeroids (ICSs), ICS and long-acting b2-agonists (LABA), orleukotriene modifiers (LM).MethODs: Study patients, selected from a privately insuredclaims database (1999-2005), had at least 1 asthma diagno-sis; no diagnosis of chronic obstructive pulmonary disease;mild persistent asthma as defined by the 2005 HealthcareEffectiveness Data and Information Set, Leidy’s reliever andoral steroid methods, and the 2004 Global Initiative for Asthmaguidelines; and initiated regular use of ICS, ICS+LABA or LM.The index date was defined as the date of the first ICS, ICS+LABA, or LM prescription fill. Wilcoxon rank-sum tests wereused for descriptive pair-wise comparison of patient outcomesand costs in the 12 months after the index date. Multivariategeneralized linear models were used to compare costs adjustingfor patient characteristics.ResUlts: The final sample included 319 patients with regularuse of ICS, 414 patients with ICS+LABA, and 550 patientswith LM. There were no significant differences in patientoutcomes, as measured by hospitalizations and emergencyroom visits (all-cause as well as asthma-specific) among the3 cohorts. Total direct costs were significantly lower with ICSand LM compared with ICS+LABA (ICS: $3,971, P<0.01 com-pared with ICS+LABA; ICS+LABA: $4,733, P<0.01 comparedwith LM; LM: $4,148) and not significantly different between

ICS and LM. Asthma-related direct costs were the lowest withICS compared with both ICS + LABA and LM (ICS: $819,P< 0.01 compared with ICS+LABA, P<0.01 compared withLM; ICS+LABA: $1,094, P<0.01 compared with LM; LM:$869). Descriptive costs results were confirmed by the multi-variate analysis.CONClUsiON: Regular ICS use in mild persistent asthma wasassociated with lower total direct costs compared with ICS+LABA and the lowest asthma-related direct costs comparedwith ICS+LABA or LM, without any corresponding differencein patient outcomes.

COSTS AND RESOURCE UTILIzATION AMONG PATIENTSWITH PROGRESSION OF PRIMARY OPEN ANGLE GLAUCOMAWalt JG,* Chiang TH, Stern L, Doyle JJ, Berenson KL Allergan, Inc., 2525Dupont Dr., Irvine, CA 92612-1599; [email protected], (714) 246-6719

BACKGROUND: Glaucoma is a disease that, with progression, canlead to blindness. Mean deviation (MD) scores are used to mea-sure the degree of visual field loss in glaucoma patients. Whileworsening MD scores may not be noticeable to the patient, theymay be a factor in driving resource utilization and costs amongglaucoma patients.OBjeCtive: To develop a health economic model to measurethe costs and resources utilized for patients with progression ofglaucoma, as evidenced by worsening MD scores.MethODs: A health economic model was used to simulateglaucoma progression for a cohort of 600 patients over 4 yearsusing chart review data and published literature. Regressionanalyses of U.S. chart review data (N = 161, mean age of 66.3years, minimum follow-up of 4 years) were conducted tocalculate the expected number of ophthalmologist visits andexams, glaucoma medications and glaucoma surgeries forpatients with progression of glaucoma; these algorithms wereincorporated in the health economic model. Unit costs wereapplied to the resource utilization estimates to calculate theexpected 4-year pharmacy and medical costs of progression.The modeled patient data were also used to predict utilityscores based on a regression analysis of utility scores amongglaucoma patients and these algorithms were used to estimatethe change in quality-adjusted life-years (QALYs) over 4 yearsof glaucoma progression.ResUlts: The 4-year cost for the cohort was $3,957 per patient($598 in pharmacy costs and $3,359 in medical costs) with 2.96QALYs accumulated over 4 years.CONClUsiONs: Glaucoma progression is associated with a lossin quality of life and an increase in medical and pharmacyresource use with a corresponding increase in health care costs.It follows that slowing glaucoma progression will purport-edly delay the loss of quality of life and postpone the resultantincrease in health care costs.


YearInpatient

(Mean + SD)Outpatient(Mean + SD)

Pharmacy(Mean + SD)

Year 1 (n = 4,791)

Year 2 (n = 4,611)

$31,067 + $97,343 $24,221 + $40,302

$23,712 + $38,568$35,619 + $123,705

$2,806 + $4,637

$3,293 + $5,644

TABLE Treatment Costs for ESRD Patients


DIFFERENCES IN COMPLIANCE AND PERSISTENCEWHEN SWITCHED FROM FIxED-DOSE TO FREECOMBINATION ANTIHYPERTENSIVE THERAPY INPATIENTS WITH HYPERTENSIONHess G,* Hill J, Lau H, Preblick R, Plauschinat CA. Surveillance DataInc. 220 West Germantown Pike, Ste. 140, Plymouth Meeting, PA 19462;[email protected], (610) 834-0800, ext. 1711

BACKGROUND: Compliance with medication therapy mayimprove outcomes in people with hypertension.OBjeCtive: To compare changes in compliance and persistencein patients with hypertension who switched from fixed-dosecombination (FDC) antihypertensive therapy to the free-combination (FC) regimen.MethODs: A retrospective cohort study of administrative claimsdata (Medstat MarketScan) was conducted. Continuously eli-gible patients from 1/2003 to 12/2005 with prescription cover-age who were diagnosed with hypertension and who received≥ 3 months of FDC, had a therapeutic change to FC, and had≥ 2 refills for each FC component thereafter were identified. Apropensity-score algorithm identified matched controls remain-ing on FDC based on gender, age, comorbidities, payer type, andtreatment time on FDC. Compliance (medication possessionratio [MPR]), persistency, days with therapy and cardiovascular(CV)-related costs were analyzed.ResUlts: A total of 14,450 patients were identified; FDC/FC(angiotensin receptor blocker + hydrochlorothiazide [ARB+HCTZ], n=2,432), FDC/FC (angiotensin-converting enzymeinhibitor + calcium channel blocker [ACEI+CCB], n=2,662);and other FDC/FC antihypertensive medications (n=9,356).Patients who switched to FC had significantly lower MPRs (P<0.0001), lower persistence, fewer number of refills (P<0.0001),

less mean days of therapy (P<0.0001), and higher CV-relatedcosts compared with patients who stayed with FDC at 12months (P<0.0001).CONClUsiONs: Switching from fixed-dose to free-combinationtherapy significantly lowered compliance and persistence at 12months. Further research is needed to better understand theimplications of therapy modifications on blood pressure controland future CV-related events.

DISSECTING THE DOSSIER: INCREASINGMANAGED CARE DECISION MAkERS’ LEVEL OF FLUENCYWITH PRODUCT DOSSIERSRaval KD,* Regan TS, Webb SF, Meyers K. Xcenda, 4114 WoodlandsPkwy., Ste. 500, Palm Harbor, FL 34685 [email protected],(727) 771-4162.

BACKGROUND: In a recent study in the Journal of Managed CarePharmacy, J. Spooner et al.1 found that although the requested dos-siers were of high quality and generally followed the AMCP Formatfor Formulary Submissions, dossier receipt did not improve the like-lihood that the product would be selected for preferred formularyplacement. As the health care dollar continues to be stretchedfurther, managed care decision makers must efficiently utilize thetools available to them when analyzing product information.OBjeCtive: The objective of this poster is to enhance managedcare decision makers’ level of fluency with the form and func-tion of product dossiers.MethODs: The layout and design of the standardized AMCPFormat for Formulary Submissions is explained in detail. Thistool is then applied to a currently available product dossier tofurther describe its function.CONClUsiONs: The AMCP Format for Formulary Submissionsguides manufacturers on how to standardize their product dos-siers to make them effective and efficient sources of clinical andeconomic information for health care decision makers.ReFeReNCe 1. Spooner JJ, Gandhi PK, Connelly SB. AMCPFormat dossier requests: manufacturer response and formularyimplications for one large health plan. J Manag Care Pharm.2007;13(1):37-43. Available at: http://www.amcp.org/data/jmcp/37-43.pdf.

DO PAYERS BELIEVE NEW CANCER DRUGSOFFER GOOD VALUE?Nadler E, Broderick WC,* Kim J, LaPensee K. i3 Innovus, 1743 SunsetBlvd., Houston, Texas 77005; [email protected], (713)520-0839

BACKGROUND: Payers play a pivotal role in access to novel can-cer treatments, yet it’s unclear whether they believe high-costtreatments offer good value.OBjeCtive: Determine payers’ perceptions of value associatedwith specific novel cancer therapies.


TABLE Study Outcomes for FC and FDC Cohorts

ARB + HCTZ(N = 1,216)

ACEI + CCB(N = 1,331)

Variable

Mean 12-monthMPR (SD)

53.59(32.44)

12-monthpersistence (%)

13.40

Mean days withtherapy (SD)

192.92(116.78)

Mean cardio-vascular relatedcosts (SD)

$3,950($12,160)

Other Anti-hypertensives

(N = 4,678)

FC FDC FC FDC FC FDC

75.43(25.60)

56.50

271.54(92.16)

$3,126($9,466)

53.95(32.42)

14.80

194.21(116.73)

$4,983($17,322)

78.65(23.73)

61.98

283.16(85.43)

$3,129($6,504)

54.67(32.74)

15.28

196.80(117.87)

$3,143($10,424)

76.72(25.11)

57.76

276.19(90.41)

$2,400($11,666)

ARB = angiotensin receptor blocker; HCTZ = hydrochlorothiazide; ACEI = angiotensin-converting enzyme inhibitor; CCB = calcium channel blocker; FC = free combination;FDC = fixed dose combination; MPR = medication posession ratio.


DIFFERENCES IN COMPLIANCE AND PERSISTENCEWHEN SWITCHED FROM FIxED-DOSE TO FREECOMBINATION ANTIHYPERTENSIVE THERAPY INPATIENTS WITH HYPERTENSIONHess G,* Hill J, Lau H, Preblick R, Plauschinat CA. Surveillance DataInc. 220 West Germantown Pike, Ste. 140, Plymouth Meeting, PA 19462;[email protected], (610) 834-0800, ext. 1711

BACKGROUND: Compliance with medication therapy mayimprove outcomes in people with hypertension.OBjeCtive: To compare changes in compliance and persistencein patients with hypertension who switched from fixed-dosecombination (FDC) antihypertensive therapy to the free-combination (FC) regimen.MethODs: A retrospective cohort study of administrative claimsdata (Medstat MarketScan) was conducted. Continuously eli-gible patients from 1/2003 to 12/2005 with prescription cover-age who were diagnosed with hypertension and who received≥ 3 months of FDC, had a therapeutic change to FC, and had≥ 2 refills for each FC component thereafter were identified. Apropensity-score algorithm identified matched controls remain-ing on FDC based on gender, age, comorbidities, payer type, andtreatment time on FDC. Compliance (medication possessionratio [MPR]), persistency, days with therapy and cardiovascular(CV)-related costs were analyzed.ResUlts: A total of 14,450 patients were identified; FDC/FC(angiotensin receptor blocker + hydrochlorothiazide [ARB+HCTZ], n=2,432), FDC/FC (angiotensin-converting enzymeinhibitor + calcium channel blocker [ACEI+CCB], n=2,662);and other FDC/FC antihypertensive medications (n=9,356).Patients who switched to FC had significantly lower MPRs (P<0.0001), lower persistence, fewer number of refills (P<0.0001),

less mean days of therapy (P<0.0001), and higher CV-relatedcosts compared with patients who stayed with FDC at 12months (P<0.0001).CONClUsiONs: Switching from fixed-dose to free-combinationtherapy significantly lowered compliance and persistence at 12months. Further research is needed to better understand theimplications of therapy modifications on blood pressure controland future CV-related events.

DISSECTING THE DOSSIER: INCREASINGMANAGED CARE DECISION MAkERS’ LEVEL OF FLUENCYWITH PRODUCT DOSSIERSRaval KD,* Regan TS, Webb SF, Meyers K. Xcenda, 4114 WoodlandsPkwy., Ste. 500, Palm Harbor, FL 34685 [email protected],(727) 771-4162.

BACKGROUND: In a recent study in the Journal of Managed CarePharmacy, J. Spooner et al.1 found that although the requested dos-siers were of high quality and generally followed the AMCP Formatfor Formulary Submissions, dossier receipt did not improve the like-lihood that the product would be selected for preferred formularyplacement. As the health care dollar continues to be stretchedfurther, managed care decision makers must efficiently utilize thetools available to them when analyzing product information.OBjeCtive: The objective of this poster is to enhance managedcare decision makers’ level of fluency with the form and func-tion of product dossiers.MethODs: The layout and design of the standardized AMCPFormat for Formulary Submissions is explained in detail. Thistool is then applied to a currently available product dossier tofurther describe its function.CONClUsiONs: The AMCP Format for Formulary Submissionsguides manufacturers on how to standardize their product dos-siers to make them effective and efficient sources of clinical andeconomic information for health care decision makers.ReFeReNCe 1. Spooner JJ, Gandhi PK, Connelly SB. AMCPFormat dossier requests: manufacturer response and formularyimplications for one large health plan. J Manag Care Pharm.2007;13(1):37-43. Available at: http://www.amcp.org/data/jmcp/37-43.pdf.

DO PAYERS BELIEVE NEW CANCER DRUGSOFFER GOOD VALUE?Nadler E, Broderick WC,* Kim J, LaPensee K. i3 Innovus, 1743 SunsetBlvd., Houston, Texas 77005; [email protected], (713)520-0839

BACKGROUND: Payers play a pivotal role in access to novel can-cer treatments, yet it’s unclear whether they believe high-costtreatments offer good value.OBjeCtive: Determine payers’ perceptions of value associatedwith specific novel cancer therapies.


TABLE Study Outcomes for FC and FDC Cohorts

ARB + HCTZ(N = 1,216)

ACEI + CCB(N = 1,331)

Variable

Mean 12-monthMPR (SD)

53.59(32.44)

12-monthpersistence (%)

13.40

Mean days withtherapy (SD)

192.92(116.78)

Mean cardio-vascular relatedcosts (SD)

$3,950($12,160)

Other Anti-hypertensives

(N = 4,678)

FC FDC FC FDC FC FDC

75.43(25.60)

56.50

271.54(92.16)

$3,126($9,466)

53.95(32.42)

14.80

194.21(116.73)

$4,983($17,322)

78.65(23.73)

61.98

283.16(85.43)

$3,129($6,504)

54.67(32.74)

15.28

196.80(117.87)

$3,143($10,424)

76.72(25.11)

57.76

276.19(90.41)

$2,400($11,666)

ARB = angiotensin receptor blocker; HCTZ = hydrochlorothiazide; ACEI = angiotensin-converting enzyme inhibitor; CCB = calcium channel blocker; FC = free combination;FDC = fixed dose combination; MPR = medication posession ratio.


MethODs: Fifty health plan/pharmacy benefit managementmedical and pharmacy directors were asked to estimate themonthly average wholesale price (AWP) and overall survival(OS) benefit for bevacizumab and erlotinib and the progression-free survival (PFS) benefit for sunitinib. Using these estimates,cost-effectiveness ratios (CERs) were calculated. Intervieweeswere then provided with the monthly AWP, OS, and PFS dataand asked whether the treatments offered “good value.” Finally,interviewees were questioned about the impact of drug costs onpatient access and formulary decisions.ResUlts: Most interviewees overestimated the cost and under-estimated the survival benefit associated with these treatments(Table). Forty-eight percent of payers felt that bevacizumaboffered “good value” compared with about one third for theother 2 drugs. Fifty-six percent said the costs of new cancerdrugs influenced their decisions about which treatments receiveoptimal reimbursement; 64% stated patients should have accessto “effective” cancer treatment regardless of cost.CONClUsiONs: A minority of interviewees thought these can-cer treatments offered good value. Cost-effectiveness ratioswere lower than the $300,000 per quality-adjusted life-yearcited by oncologists but higher than the $50,000 standardoften cited. Cost influenced most payers’ formulary decisionsabout these treatments but should not limit patients’ accessto “effective” care. Findings reflect the need for stronger edu-cation about the cost and effectiveness of these drugs as newtherapies emerge.

DRUG UTILIzATION AND ASSOCIATED COSTS OFERYTHROPOIESIS-STIMULATING AGENTS IN MANAGEDCARE PATIENTS WITH CANCER RECEIVING CHEMOTHERAPYBarron JJ, Mody SH, McKenzie RS,* Bookhart BK, Grochulski WD. OrthoBiotech Clinical Affairs, 4328 Goodfellow, Dallas, TX 75229; [email protected], (214) 692-7886

OBjeCtive AND PURPOse: This retrospective, observationalstudy was performed from a managed care perspective to ana-lyze current dosing patterns and associated costs of epoetin

alfa (EPO) and darbepoetin alfa (DARB) in patients with cancerreceiving chemotherapy.MethODs: Patients who were aged at least 18 years, had cancerand were receiving chemotherapy, had at least 2 EPO or DARBclaims, and were newly initiated on erythropoietic therapy wereselected from de-identified medical claims of regionally diversehealth plans between first quarter 2002-second quarter 2006.EPO and DARB use was identified via Health Care CommonProcedure Coding System codes in medical claims with dosecalculated using billed units. Dosing frequency, mean cumula-tive dose, and drug costs (using January 2007 wholesale acqui-sition prices; EPO $12.52 per 1,000 units; DARB $4.576 per 1mcg) were calculated for each group.ResUlts: A total of 4,263 EPO and 4,525 DARB patientsmet inclusion criteria. Mean age (56.6±12.6 years for EPOpatients and 56.4±12.3 years for DARB patients, P=0.48),was similar between groups, with slightly more women com-prising the DARB group (EPO group=73% women; DARBgroup=75% women, P=0.03). Weekly and extended (greaterthan or equal to every 2 weeks (Q2W) dosing frequencieswere utilized in patients receiving EPO (QW: 46.7%, Q2W:41.2%,≥Q3W: 12.1%) and DARB (QW: 10.1%, Q2W: 55.2%,≥Q3W: 34.7%). Mean duration of therapy was 61±53 daysfor EPO and 61±46 days for DARB. Mean cumulative dosefor EPO and DARB was 292,035 units and 1,099 mcg, respec-tively, corresponding to a dose ratio of 266:1 (units EPO: mcgDARB) and erythropoiesis-stimulating agent drug cost of$3,656 and $5,029, respectively.CONClUsiON: Extended EPO and DARB dosing (greater thanor equal to Q2W) were common among patients with cancerreceiving chemotherapy. However, cumulative drug costs asso-ciated with EPO and DARB differed, with EPO patients having27% lower drug costs as compared with DARB patients.

ECONOMIC AND CLINICAL EVALUATION OF GENERICSELECTIVE SEROTONIN REUPTAkE INHIBITOR UTILIzATIONIN A STAFF-MODEL MANAGED CARE ORGANIzATIONPrasla K,* Flentge N, Godley PJ, Clanton C, Chaddick J. Scott and WhiteHealth Systems, 2601 Thornton Lane, Ste. A, Temple, TX 76502;[email protected], (254) 724-7730

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs)have become major contributors to the overall drug spend inmany managed care organizations. Health plans can reduceoverall SSRI expenditure by increasing generic utilization.OBjeCtive: The primary objective is to evaluate the utilizationand costs associated with increased generic usage of SSRIs ina managed care organization. The secondary objective is toevaluate clinical implications associated with conversion frombranded to generic SSRIs.MethODs: This is a retrospective analysis of prescriptionclaims data from January 2001 through December 2005.


TABLE Summary of Key Results

Drug

Mean EstimatedAWP per Month(Actual)

Mean Estimate ofIncremental MedianOS/PFS (actual) Mean CER % Good Value

Bevacizumab

Erlotinib

Sunitinib

$5,750 ($4,800) 4.6 OS (4.7) $180,000/QALY

48

$171,670/QALY

$170,000/QALY

28

32

3.5 OS (2.0)

4.2 PFS (9.4)

$4,134 ($3,350)

$5,007 ($7,700)

AWP = average wholesale price; OS = overall survival; PFS = progression-free survival;CER = cost-effectiveness ratio; QALY = quality-adjusted life-years.


MethODs: Fifty health plan/pharmacy benefit managementmedical and pharmacy directors were asked to estimate themonthly average wholesale price (AWP) and overall survival(OS) benefit for bevacizumab and erlotinib and the progression-free survival (PFS) benefit for sunitinib. Using these estimates,cost-effectiveness ratios (CERs) were calculated. Intervieweeswere then provided with the monthly AWP, OS, and PFS dataand asked whether the treatments offered “good value.” Finally,interviewees were questioned about the impact of drug costs onpatient access and formulary decisions.ResUlts: Most interviewees overestimated the cost and under-estimated the survival benefit associated with these treatments(Table). Forty-eight percent of payers felt that bevacizumaboffered “good value” compared with about one third for theother 2 drugs. Fifty-six percent said the costs of new cancerdrugs influenced their decisions about which treatments receiveoptimal reimbursement; 64% stated patients should have accessto “effective” cancer treatment regardless of cost.CONClUsiONs: A minority of interviewees thought these can-cer treatments offered good value. Cost-effectiveness ratioswere lower than the $300,000 per quality-adjusted life-yearcited by oncologists but higher than the $50,000 standardoften cited. Cost influenced most payers’ formulary decisionsabout these treatments but should not limit patients’ accessto “effective” care. Findings reflect the need for stronger edu-cation about the cost and effectiveness of these drugs as newtherapies emerge.

DRUG UTILIzATION AND ASSOCIATED COSTS OFERYTHROPOIESIS-STIMULATING AGENTS IN MANAGEDCARE PATIENTS WITH CANCER RECEIVING CHEMOTHERAPYBarron JJ, Mody SH, McKenzie RS,* Bookhart BK, Grochulski WD. OrthoBiotech Clinical Affairs, 4328 Goodfellow, Dallas, TX 75229; [email protected], (214) 692-7886

OBjeCtive AND PURPOse: This retrospective, observationalstudy was performed from a managed care perspective to ana-lyze current dosing patterns and associated costs of epoetin

alfa (EPO) and darbepoetin alfa (DARB) in patients with cancerreceiving chemotherapy.MethODs: Patients who were aged at least 18 years, had cancerand were receiving chemotherapy, had at least 2 EPO or DARBclaims, and were newly initiated on erythropoietic therapy wereselected from de-identified medical claims of regionally diversehealth plans between first quarter 2002-second quarter 2006.EPO and DARB use was identified via Health Care CommonProcedure Coding System codes in medical claims with dosecalculated using billed units. Dosing frequency, mean cumula-tive dose, and drug costs (using January 2007 wholesale acqui-sition prices; EPO $12.52 per 1,000 units; DARB $4.576 per 1mcg) were calculated for each group.ResUlts: A total of 4,263 EPO and 4,525 DARB patientsmet inclusion criteria. Mean age (56.6±12.6 years for EPOpatients and 56.4±12.3 years for DARB patients, P=0.48),was similar between groups, with slightly more women com-prising the DARB group (EPO group=73% women; DARBgroup=75% women, P=0.03). Weekly and extended (greaterthan or equal to every 2 weeks (Q2W) dosing frequencieswere utilized in patients receiving EPO (QW: 46.7%, Q2W:41.2%,≥Q3W: 12.1%) and DARB (QW: 10.1%, Q2W: 55.2%,≥Q3W: 34.7%). Mean duration of therapy was 61±53 daysfor EPO and 61±46 days for DARB. Mean cumulative dosefor EPO and DARB was 292,035 units and 1,099 mcg, respec-tively, corresponding to a dose ratio of 266:1 (units EPO: mcgDARB) and erythropoiesis-stimulating agent drug cost of$3,656 and $5,029, respectively.CONClUsiON: Extended EPO and DARB dosing (greater thanor equal to Q2W) were common among patients with cancerreceiving chemotherapy. However, cumulative drug costs asso-ciated with EPO and DARB differed, with EPO patients having27% lower drug costs as compared with DARB patients.

ECONOMIC AND CLINICAL EVALUATION OF GENERICSELECTIVE SEROTONIN REUPTAkE INHIBITOR UTILIzATIONIN A STAFF-MODEL MANAGED CARE ORGANIzATIONPrasla K,* Flentge N, Godley PJ, Clanton C, Chaddick J. Scott and WhiteHealth Systems, 2601 Thornton Lane, Ste. A, Temple, TX 76502;[email protected], (254) 724-7730

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs)have become major contributors to the overall drug spend inmany managed care organizations. Health plans can reduceoverall SSRI expenditure by increasing generic utilization.OBjeCtive: The primary objective is to evaluate the utilizationand costs associated with increased generic usage of SSRIs ina managed care organization. The secondary objective is toevaluate clinical implications associated with conversion frombranded to generic SSRIs.MethODs: This is a retrospective analysis of prescriptionclaims data from January 2001 through December 2005.


TABLE Summary of Key Results

Drug

Mean EstimatedAWP per Month(Actual)

Mean Estimate ofIncremental MedianOS/PFS (actual) Mean CER % Good Value

Bevacizumab

Erlotinib

Sunitinib

$5,750 ($4,800) 4.6 OS (4.7) $180,000/QALY

48

$171,670/QALY

$170,000/QALY

28

32

3.5 OS (2.0)

4.2 PFS (9.4)

$4,134 ($3,350)

$5,007 ($7,700)

AWP = average wholesale price; OS = overall survival; PFS = progression-free survival;CER = cost-effectiveness ratio; QALY = quality-adjusted life-years.


The following brand and, if available, generic SSRI medica-tions were evaluated for utilization and health plan paid:citalopram, escitalopram, fluoxetine, paroxetine, and sertra-line. Electronic medical record was used to assess clinicaloutcomes of 100 randomly selected patients who were onbranded sertraline for at least 6 months prior to switching tofluoxetine between 2001 and 2002. Switched patients wereevaluated for adverse effects and therapy modifications fol-lowing conversion to fluoxetine.ResUlts: The health plan increased its generic utiliza-tion from 7% (2001) to 78% (2005). In 2005, fluoxetineaccounted for 46% of the generic utilization. This resultedin a 58% decrease in total health plan paid from $1,812 per1,000 members per month (P1000MPM) in 2001 to $765P1000MPM in 2005. A total of 19 adverse effects and 26 casesof either increased fluoxetine dosage or a switch in antide-pressant therapy were reported.CONClUsiON: The analysis resulted in a 71% increase ingeneric SSRI utilization from its introduction in 2001 untilthe end of the study period in 2005. This increase in genericSSRI usage decreased the health plan paid P1000MPM by$1,047 over the study period. Adverse effects and dosemodifications were reported in patients who switched frombranded sertraline to fluoxetine; however, further analysisneeds to be conducted to determine the exact frequency andclinical significance of the outcomes.

THE ECONOMIC BURDEN OF SELECTIVE SEROTONINTREATMENT FAILURE IN A MANAGED CARE POPULATIONBalkrishnan R,* Seal B, Mullins CD. The Ohio State University, College ofPharmacy, 500 West 12th Ave., 136-C, Columbus, OH 43210;[email protected], (614) 292-6415

iNtRODUCtiON: Major depressive disorder (MDD) costs aresignificant and could be affected by the success of treat-ment prescribed. Selective serotonin reuptake inhibitors(SSRIs) are typically the first line of antidepressant therapy.However, due to the low incidence of remission rates,patients’ medication is often switched to or augmented withother antidepressants, either in the same class or outside.The objective of this study was to determine the economicburden to managed care due to failure of SSRI therapy interms of direct medical costs.MethODs: A retrospective analyses of the PHARMetricsdatabase, a national managed care medical and pharmacyclaims dataset of 1.9 million MDD subjects between January2003 to June 2005 was conducted. Individuals with SSRItreatment failure were identified using a published antide-pressant use algorithm based on switch or augmentation toa different drug, regardless of class. A pre-post comparisonof annual medical cost increases following new SSRI treat-ment was performed and differences in mean cost increases

for the SSRI-failure vs. nonfailure groups were calculatedusing t tests and confirmed using multivariate linear regres-sion models.ResUlts: The percentage of subjects with likely SSRI treat-ment failure was 30.7% (n = 2,595). The mean (SD) increasein total direct medical costs was $6,489 ($24,564) for theSSRI treatment failure cohort compared with the $3,257($17,669) increase in the nonfailure cohort. The majorcomponents of these cost increases were outpatient costincreases of $2,579 ($10,125) vs. $1,309 ($6,424); inpatientcost increases of $2,862 ($19,962) vs. $1,532 ($14,977); andincreases in antidepressant costs of $616 ($2,018) vs. $283($2,065) for likely SSRI treatment-failure and nonfailurecohorts, respectively. All differences were statistically sig-nificant at P < 0.001. These findings were upheld in multi-variate regression analyses.CONClUsiONs: The increased costs of MDD are substantialfollowing the onset of a new SSRI treatment episode andsignificantly higher among patients with likely SSRI treat-ment failure.

EFFECT OF NEBULIzED ARFORMOTEROL ANDSALMETEROL MDI ON SHORT-ACTING BRONCHODILATORUSE AMONG SUBJECTS WITH COPD IN A 52-WEEk TRIALDonohue JF, Hanania NA, Sciarappa K, Grogan DR, Baumgartner RA,Hanrahan JP.* Sepracor, Inc., 84 Waterford Dr., Marlborough, MA 01752;[email protected], (508) 357-7320

iNtRODUCtiON: The use of as-needed short-acting inhaled bron-chodilator medications to supplement long-acting beta2-agonist(LABA) treatment, and the frequency of clinical exacerbationswere assessed during 52 weeks of treatment with either arfor-moterol or salmeterol in subjects with chronic obstructive pul-monary disease (COPD).MethODs: Participants (mean FEV1 =1.2 L, 41% predicted)were randomized to nebulized arformoterol 50 µg dosed oncedaily (n=528) or salmeterol 42 µg dosed twice per day via (n=265) in a multicenter, open-label, 52-week trial. Change fromthe 1-week baseline run-in period in inhaled rescue albuteroland supplemental ipratropium bromide was determined. Thenumber of days in which as-needed medications were usedeach week (days per week) and the number of actuations usedeach day (actuations per day) were calculated over 13-weekintervals. COPD exacerbations, defined as worsening respira-tory symptoms requiring a change in medications, were alsoevaluated.ResUlts: Decreases in albuterol and ipratropium use wereobserved in both treatment groups, and remained stable over52 weeks (Table). COPD exacerbation frequency also did notincrease over time (Weeks 0-13: 15.7% and 11.7% for arfor-moterol and salmeterol, respectively; Weeks 39-52: 10.0% and9.4%, respectively).



CONClUsiON: In this trial, the data suggest that no toleranceto LABA therapy occurred over 52 weeks as demonstrated bya decrease in short-acting bronchodilator-use and a stable fre-quency of COPD exacerbations. These data support the long-term bronchodilation efficacy of these LABAs in the treatment ofCOPD. The conclusions were unaltered in an analysis restrictedto subjects who had data in the last interval (Weeks 39-52).

THE EFFECT OF DAILY OUTBOUND CALLING AS APROACTIVE APPROACH TO DRIVE FORMULARY SUBSTITUTIONYoder DM,* and Orlaskey PC. Bravo Health, 3601 O’Donnell St.,Baltimore, MD 21224; [email protected], (410) 864-4583

OBjeCtive: To examine the effect of daily outbound calling topharmacies and physicians on formulary substitution.BACKGROUND: The Elder Health formulary has step-therapypolices on 2 major drug classes, the proton pump inhibitors(PPIs) and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (HMGs), where the generic productsare covered as first-line. Since this was new for 2007, it wassuspected that a large number of patients would have to make aformulary substitution or request a prior authorization.MethODs: Elder Health receives a daily file from our pharmacybenefits manager (PBM) that contains all of the previous days“rejected” claims at the point of sale. Using this list, rejectionsfor brand name PPIs and HMGs were identified and outboundcalls were placed to both pharmacies and physicians to urgethem to substitute to a generic equivalent rather than request aprior authorization. This represented a more proactive approachto driving formulary substitution than is the industry standard.Calls were made during January 2007 and post-analysis was per-formed in March 2007.

ResUlts:

CONClUsiONs: The program shows a high rate of success althoughit is impossible to directly link outbound calls with a formularysubstitution. Since the physician only had 2 choices—switch to ageneric product or seek prior authorization—a follow-up analysisof prior authorization attempts may be beneficial to shed morelight on the physician’s behavior.

EFFECTIVENESS OF EzETIMIBE MONOTHERAPYFOR THE MANAGEMENT OF HYPERCHOLESTEROLEMIAIN A MANAGED CARE CLAIMS DATABASEFriedman HS,* Rajagopalan S, Barnes JP, Prentice RD. Analytic Solutions,LLC, 26 Prince St., Ste. 2B, New York, NY 10012; [email protected], (917) 576-4927

iNtRODUCtiON: Ezetimibe is in a class of lipid-lowering com-pounds that selectively inhibit the intestinal absorption of choles-


OutboundCalls

UniqueMembers

SuccessfulSubstitutions

SubstitutionRate (%)

3563 1427 854 59.85

TABLE 1 Pharmacy Calls

TABLE 2 Pharmacy Call Subgroup Analysis

DrugClass

TotalRejections

UniqueMembers



PPI

PPI = proton pump inhibitors, HMG = 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitor.

2495311219 46.89

HMG 60510552630 57.35

OutboundCalls

UniqueMembers



147 86 51 59.30

TABLE 3 Physician Calls

TABLE 4 Physician Call Subgroup Analysis

DrugClass

TotalRejections

UniqueMembers



PPI

PPI = proton pump inhibitors. HMG = 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitor.

777 100

HMG 4479140 55.70

TABLE

Arformoterol Salmeterol

Weeks 0-13M (SD) ChangeFrom Baseline




Rescuealbuterol

Days per week -1.10 (3.0) -0.87 (2.7) -0.94 (2.9)

Actuationsper day -1.09 (2.9) -0.87 (2.6) -0.78 (2.9)

SupplementalIpratropium

Days per week -1.53 (3.5) 1.42 (3.0) -1.74 (3.3)

Actuationsper day

-1.55 (3.2) -1.21 (2.6) -1.26 (3.0)

Variable

-1.07 (2.5)

-0.97 (2.4)

-1.33 (2.9)

-1.32 (2.7)

Rescue Albuterol and SupplementalIpratropium Use Over 52 Weeks


CONClUsiON: In this trial, the data suggest that no toleranceto LABA therapy occurred over 52 weeks as demonstrated bya decrease in short-acting bronchodilator-use and a stable fre-quency of COPD exacerbations. These data support the long-term bronchodilation efficacy of these LABAs in the treatment ofCOPD. The conclusions were unaltered in an analysis restrictedto subjects who had data in the last interval (Weeks 39-52).

THE EFFECT OF DAILY OUTBOUND CALLING AS APROACTIVE APPROACH TO DRIVE FORMULARY SUBSTITUTIONYoder DM,* and Orlaskey PC. Bravo Health, 3601 O’Donnell St.,Baltimore, MD 21224; [email protected], (410) 864-4583

OBjeCtive: To examine the effect of daily outbound calling topharmacies and physicians on formulary substitution.BACKGROUND: The Elder Health formulary has step-therapypolices on 2 major drug classes, the proton pump inhibitors(PPIs) and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (HMGs), where the generic productsare covered as first-line. Since this was new for 2007, it wassuspected that a large number of patients would have to make aformulary substitution or request a prior authorization.MethODs: Elder Health receives a daily file from our pharmacybenefits manager (PBM) that contains all of the previous days“rejected” claims at the point of sale. Using this list, rejectionsfor brand name PPIs and HMGs were identified and outboundcalls were placed to both pharmacies and physicians to urgethem to substitute to a generic equivalent rather than request aprior authorization. This represented a more proactive approachto driving formulary substitution than is the industry standard.Calls were made during January 2007 and post-analysis was per-formed in March 2007.

ResUlts:

CONClUsiONs: The program shows a high rate of success althoughit is impossible to directly link outbound calls with a formularysubstitution. Since the physician only had 2 choices—switch to ageneric product or seek prior authorization—a follow-up analysisof prior authorization attempts may be beneficial to shed morelight on the physician’s behavior.

EFFECTIVENESS OF EzETIMIBE MONOTHERAPYFOR THE MANAGEMENT OF HYPERCHOLESTEROLEMIAIN A MANAGED CARE CLAIMS DATABASEFriedman HS,* Rajagopalan S, Barnes JP, Prentice RD. Analytic Solutions,LLC, 26 Prince St., Ste. 2B, New York, NY 10012; [email protected], (917) 576-4927

iNtRODUCtiON: Ezetimibe is in a class of lipid-lowering com-pounds that selectively inhibit the intestinal absorption of choles-


OutboundCalls

UniqueMembers



3563 1427 854 59.85

TABLE 1 Pharmacy Calls

TABLE 2 Pharmacy Call Subgroup Analysis

DrugClass

TotalRejections

UniqueMembers



PPI

PPI = proton pump inhibitors, HMG = 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitor.

2495311219 46.89

HMG 60510552630 57.35

OutboundCalls

UniqueMembers



147 86 51 59.30

TABLE 3 Physician Calls

TABLE 4 Physician Call Subgroup Analysis

DrugClass

TotalRejections

UniqueMembers



PPI

PPI = proton pump inhibitors. HMG = 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitor.

777 100

HMG 4479140 55.70

TABLE

Arformoterol Salmeterol





Rescuealbuterol

Days per week -1.10 (3.0) -0.87 (2.7) -0.94 (2.9)

Actuationsper day -1.09 (2.9) -0.87 (2.6) -0.78 (2.9)

SupplementalIpratropium

Days per week -1.53 (3.5) 1.42 (3.0) -1.74 (3.3)

Actuationsper day

-1.55 (3.2) -1.21 (2.6) -1.26 (3.0)

Variable

-1.07 (2.5)

-0.97 (2.4)

-1.33 (2.9)

-1.32 (2.7)

Rescue Albuterol and SupplementalIpratropium Use Over 52 Weeks


terol and related phytosterols. Clinical trials have demonstratedthat ezetimibe monotherapy is effective at reducing low-densitylipoprotein cholesterol (LDL-C) levels by 18%, but there has beenlittle examination of the effectiveness in clinical practice.MethODs: In a retrospective, longitudinal study, data wereexamined between July 1, 2004 and September 30, 2006 from aclaims database. Patients > 18 years. initiating ezetimibe mono-therapy were identified by their ezetimibe prescription (indexdate) and were required to have no other lipid-lowering therapyprescriptions 6 months pre-index. Patients were required tohave a serum cholesterol measurement within 6 months priorto the index date and again 1 to 3 months after the index date;there was no change in lipid-lowering therapy from index dateto first serum cholesterol measurement. Patients were catego-rized into risk categories using revised Adult Treatment PanelIII (ATP III) guidelines. Patients were characterized by historyof risk factors, comorbidities, and LDL-C goals as defined byrisk category. Patients at LDL-C goal at baseline and in the lowrisk category were excluded.ResUlts: Ezetimibe monotherapy patients (n=636) were identi-fied having. Their mean age was 57.1 years (SD=10.1), 46.4% ofpartients were female and 39.9% were diabetic. At baseline, lipidlevels were 235.2 (SD=34.7) mg/dL, 151.9 (SD=29.5) mg/dL,50.8 (SD=15.0) mg/dL for total cholesterol, LDL-C, and high-density lipoprotein cholesterol respectively. Nearly 40% of theezetimibe monotherapy patients reached goal within months 1to 3 of the index date with an average decline in LDL-C measureof 30.5 mg/dL (SD=28.4) or 19.3% (SD = 18.2%). The subcohortof diabetes patients (n=254) had an average LDL-C decline of28.3 mg/dL (SD=29.6) or 18.9% (SD=20.5%).CONClUsiON: LDL-C reduction from ezetimibe monotherapytreatment in clinical practice was similar to that found in clinicaltrials. Ezetimibe monotherapy offers a treatment alternative forpatients with hypercholesterolemia, including those with diabe-tes, not on statins or for whom stain therapy is inappropriate.

EFFECTS OF THE MEDICARE PART D PROGRAM ONPRESCRIPTION DRUG UTILIzATION AND ExPENDITURESSun SX,* Mu Y, Lee KY, Miller SA, Bertram CT, Langman J. WalgreensHealth Services, 1415 Lake Cook Rd., MS L444, Deerfield, IL 60015;[email protected], (847) 964-6928

BACKGROUND: Medicare began paying for prescription drugsfor millions of Part D beneficiaries on January 1, 2006. Littleis known regarding the impact of this program on pharmacyutilization and expenditures.OBjeCtive: To evaluate the impact of the Medicare Part D pro-gram on medication utilizations and expenditures by comparingPart D enrollees with commercial prescription plan enrollees.MethODs: Based on prescription records from a national phar-macy benefit manager from January 1, 2005 to December 31,2006, we estimated the impact of the Part D drug benefit using

a difference-in-difference approach. The study group was com-posed of members who were enrolled in Part D prescription drugplans. The control group included members who were enrolledin commercial prescription plans. Members were included ifthey were aged 65 years or older as of January 1, 2006, and werecontinuously enrolled in Part D or commercial plans.ResUlts: We identified 22,777 Part D members for the studygroup and 129,381 commercial members for the control group.From 2005 to 2006 in the study group, the average number ofprescription days of therapy increased from 839 to 985 andthe average plan costs increased from $960 to $1280, but theaverage out-of-pocket costs decreased from $361 to $333. In thecontrol group, the prescription days of therapy increased from764 to 782, the plan costs increased from $1,080 to $1,177,and out-of-pocket costs increased from $340 to $342. Using adifference-in-difference approach, we estimated that MedicarePart D increased prescription drug utilization by 128 days oftherapy (16.78%, P<0.0001), increased plan costs by $223(20.65%, P<0.0001), and reduced members’ out-of-pocket costsby $30 (21.68%, P=0.0222).CONClUsiONs: Medicare Part D program increased prescriptiondrug utilization but reduced out-of-pocket expenses for Part Denrollees. Further studies based on large national database arewarranted to corroborate the finding.

EVALUATING THE IMPACT OF THE PROPOSED NATIONALPSORIASIS FOUNDATION 2-TIERED CATEGORIzATION OFSEVERITY IN TREATING PLAqUE PSORIASIS: A PRELIMINARYCOST-EFFECTIVENESS MODELGoldberg LD,* 2210 W. Main St., Ste. 107-384, Battle Ground, WA98604; [email protected], (360) 687-9548

OBjeCtive AND PeRsPeCtive: The assessment of disease sever-ity for the purpose of guiding the pharmacologic therapy ofchronic plaque psoriasis (CPP) has been very challenging inthat the classification systems used in clinical trials are notpart of the standard of care. To address this issue, the NationalPsoriasis Foundation recently issued a consensus statementcalling for a 2-tiered categorization of severity to guide treat-ment. This model is designed to provide an example of how acost-effectiveness (CE) tool could be used to evaluate the impactof this proposal.MethODs: An Excel-based CE model was developed to com-pare the relative cost components in the treatment of moderateto severe CPP. The primary economic end point was the costof therapy (defined as the cost of drugs, laboratory, infusion,and professional services) per Psoriasis Area and SeverityIndex (PASI-75) response achieved. As an example of a tieredapproach, a CE analysis of initial treatment was conducted witha topical retinoid agent (tazarotene) and switching to a biologicagent (alefacept, efalizumab, etanercept, infliximab) with treat-ment failure vs. initial treatment with a biologic agent (for a



total of 10 treatment scenarios evaluated). Results were dis-played for a time horizon of 18-months and one-way sensitivityanalyses were conducted.ResUlts: In a typical managed care population, with an esti-mated prevalence of moderate to severe CPP of 0.53% andwith 7.5% of cases being candidates for biologic therapy, theprojected impact of treatment is $0.42 per member per month(PMPM) for initial treatment with tazarotene and $0.50 PMPMfor initial treatment with biologic agents.CONClUsiON: This preliminary research suggests that adoptingand implementing a 2-tier approach to the management of CPPas proposed by the National Psoriasis Foundation may proveto be cost-effective. Much further research need to done in thisarea to develop robust economic models to assess the potentialimpact of clinical treatment algorithms as they are developed.

EVALUATION OF AN OMEPRAzOLE OVER-THE-COUNTERINITIATIVE ON OVERALL PROTON PUMP INHIBITORExPENDITURE FOR A MANAGED CARE ORGANIzATIONPrasla K,* Godley PJ, Clanton C, Chaddick J. Scott and White HealthSystems, 2601 Thornton Lane, Ste. A, Temple, TX 76502;[email protected], (254) 724-7730

BACKGROUND: To reduce proton pump inhibitor (PPI) expendi-ture and potentially minimize the impact of PPIs on memberdrug coverage limits, the Scott and White Health Plan’s (SWHP)Pharmacy and Therapeutics (P&T) Committee selected omepra-zole OTC (over the counter) as the recommended PPI for its186,000 members. Other health plans have added omeprazoleOTC as the “preferred” product to their drug benefit coverage;however, SWHP decided against that approach. The previously“preferred” PPI, rabeprazole, was moved from a copayment of$20.00 to $50.00, and members were encouraged to purchaseomeprazole OTC at a retail price of approximately $20.00 per30-day supply.OBjeCtive: To determine health plan cost and gauge memberresponse to an omeprazole OTC initiative targeted to reduceoverall PPI expenditure.MethODs: The study period of 48 months (January 1, 2002through December 31, 2005) was equally divided for a pre- andpost-initiative comparison. The pharmacy claims database wasused to identify all PPI utilization and cost during the studyperiod. Prior authorization requests for all PPIs were used as anindicator to determine member response to the initiative.ResUlts: The initiative resulted in the total branded PPI claimscount decreasing from 23 per 1,000 members per month(P1000MPM) to 8 P1000MPM (67%). The total paid by thehealth plan decreased by 72% from $2,357 P1000MPM to $654P1000MPM. This produced a total savings of about $6.7 millionfor the 24-month post-initiative period. Of the total number ofmembers on a branded PPI before the initiative (3,791), the PPIprior-authorization request rate increased from 2.5% to 7.0%

during the post-initiative period, with a 90% approval rate.CONClUsiON: The omeprazole OTC initiative, with neutral out-of-pocket member costs and potential benefits in preservingmember prescription drug coverage, resulted in greater than70% savings in PPI drug costs. Overall, member response to theinitiative was favorable.

FACTORS INFLUENCING ANTIDEPRESSANTTREATMENT PATTERNS IN A MANAGED CAREPOPULATION WITH MAJOR DEPRESSIVE DISORDER (MDD)Schultz JS, Joish VAN.* Sanofi-aventis, 55 Corporate Dr., Bridgewater, NJ08807; [email protected], (908) 981-5169

BACKGROUND: While there are a variety of antidepressantmedications available, factors influencing treatment patterns orchoice are unclear.OBjeCtive: To determine demographic/comorbid character-istics influencing antidepressant therapy in a managed carepopulation.MethODs: A retrospective claims analysis using a national,employment-based health plan database was conducted. Indexdate was defined based on antidepressant prescription claims(tricyclics [TCA]; selective serotonin reuptake inhibitors [SSRIs];serotonin and norepinephrine reuptake inhibitors [SNRIs]; orbupropion, mirtazapine, nefazadone, or trazodone [OTHER])between January 1, 2003 and June 30, 2005. Participants weretreatment-naïve 6 months prior to the index date, continuouslyenrolled, and had at least 1 outpatient based medical claim fordepression (International Classification of Diseases, Ninth Revisioncode 296.2x or 296.3x) throughout the study period. Treatmentpattern cohorts (switchers, augmenters, and maintainers) weredefined based on prescription refill pattern 12 months afterindex therapy. Baseline characteristics were compared univari-ately and then multivariately using logistic regression models toestimate the likelihood of switch or augment after controllingfor baseline characteristics.ResUlts: Of 47,378 individuals who met study criteria, 66% (n= 31,107) were classified as maintainers, 29% (n=13,836) wereclassified as switchers, and 5% (n=2,435) were classified asaugmenters. On the index date, 65% of individuals (n=30,992)took a SSRI class of antidepressant, 11% (n=5,257) took aSNRI class of antidepressant, 4% (n=1,990) took a TCA classof antidepressant, and 19% (n=9,139) took an OTHER classof antidepressant. There were no demographic, regional, plan,payer, or out-of-pocket copay differences (P>0.05) among treat-ment patterns. However, average days on antidepressant therapywas lowest (P<0.001) for maintainers (172; SD=112.9), followedby switchers (216; SD=96.7), but greatest in augmenter cohort(239; SD=90.0) in the follow-up period. Switchers (36%) hadsignificantly (P<.001) higher psychiatric-related comorbiditiescompared with augmenters (30%) or maintainers (27%) basedon medical and prescription use. After controlling for all base-



line characteristics, those that initiated TCA therapy (n=1,096)were 1.6 times more likely (95% confidence interval, 1.51-1.83)to switch and 0.8-0.6 times less likely to augment therapy com-pared with the OTHER cohort (P<0.001).CONClUsiON: People with major depressive disorder who switchtherapy have greater comorbidity compared with nonswitchers.The initial choice of antidepressant significantly predicted theprobability of switching or augmenting medication.

HEALTH CARE COST COMPARISONS BY POINT-OF-SERVICE FOR EMPLOYEES WITH OR WITHOUT INSOMNIABrook RA,* Kleinman, NL, Melkonian AK, Doan JF, Baran RW.Retrospective Analysis, The JeSTARx Group, 18 Hirth Dr., Newfoundland,NJ 07435; [email protected], (973) 208-8621

BACKGROUND: Insomnia affects up to 10% of the adult popula-tion and is a significant public health burden.OBjeCtive AND PURPOse: To compare the costs of health care bypoint of service for employees with or without insomnia.MethODs: Retrospective analysis was conducted using anemployer database containing medical claims, payroll, anddemographic data from 2001-2006. Employees with insomniawere identified based on history of hypnotic drug use or diag-nosis of a sleep disorder (International Classification of Diseases,Ninth Revision). Diagnostic codes for insomnia included: 307.41(transient disorder of initiating or maintaining sleep), 307.42(persistent disorder of initiating or maintaining sleep), 307.49(subjective insomnia), and 780.52 (insomnia). The control groupincluded employees with no history of hypnotic drug use orinsomnia diagnosis. Annual health care costs (physician officevisit, inpatient hospital, outpatient hospital or clinic, emergencydepartment, laboratory, and other) were compared between the2 groups. The insomnia group index date was defined as firstdiagnosis date or hypnotic claim, with the average insomniagroup index date used for the control group. Annual cost differ-ences between groups were determined using a 2-part regres-sion model (due to skewed cost data), controlling for age, gender,marital status, race, salary, geographic regions, comorbid mentaldisorders, and other job-related variables.ResUlts: Data were collected for 111,385 employees (7,511insomnia, 103,874 control). Employees in the insomnia groupwere, on average, younger (1.65 years), female, white, workedfull time, and were compensated $12,316 more in annual salaryper person than controls. The insomnia group’s annual healthcare costs were significantly greater (P≤0.0001) than the con-trol group’s (physician’s office visit, $1,254 vs. $596; inpatienthospital, $1,261 vs. $600; outpatient hospital or clinic, $1,744vs. $759; emergency department, $80 vs. $43; laboratory, $22vs. $6; and other, $101 vs. $30), totaling an additional $2,428per person annually.CONClUsiONs: Employees with insomnia incurred significantlyhigher health care costs at all point-of-service locations.

IMPACT OF ANTI-TUMOR NECROSIS FACTORS ON HEALTHCARE COSTS IN PATIENTS WITH RHEUMATOID ARTHRITISTang B,* Rahman M, Stephenson JJ, Quimbo R, Thompson H, Dabbous O,Ahmad BN. Centocor Inc., 800 Ridgeview Dr., Horsham, PA 19044; [email protected]; (215) 325-4237

OBjeCtive: To evaluate the impact of anti-tumor necrosis fac-tor (TNF) therapy on health care costs in rheumatoid arthritis(RA) patients.MethODs: Two groups of patients were identified utilizingclaims data from Blue Cross Blue Shield health plans: GroupA-RA patients who initiated anti-tumor necrosis factor (anti-TNF) therapy (adalimumab, etanercept or infliximab) betweenJanuary 1, 2003 and June 30, 2005 and Group B-RA patientswithout anti-TNF therapy. The groups were matched for gen-der, age, and geographic region (3 controls: 1 TNF user). Theindex date for Group A was defined as the date of first anti-TNFtherapy and Group B patients were assigned the index date oftheir matched case. All patients were continuously enrolled ≥ 6months before and ≥ 12 months after the index date. RA-relatedand total health care expenditures, excluding TNF drug cost,were calculated for the pre- and post-index periods. Multivariateanalyses, controlling for potential confounders, were performedto compare per-member-per-month (PMPM) expenditures.ResUlts: There were 9,545 RA patients (2,405 in Group A and7,140 in Group B) and 70.5% were female with an average ageof 48.0 years. In the pre-index period, Group A had higher RA-related PMPM ($211 versus $32, P<0.0001) and total healthcare costs ($711 vs. $503, P<0.0001) than Group B. Comparedwith the pre-index period, RA-related PMPM costs (exclud-ing TNF drugs) decreased for Group A by $44 (-20.9%) butincreased for Group B by $3 (+9.5%; P=0.0332) during the post-index period. After adjusting for confounding variables, RA-related cost differences from pre- to post-index period remainedbetween TNF users and controls (P=0.0049).CONClUsiONs: Although RA TNF users’ pre-index RA-relatedcosts were significantly higher, their post-index RA-related costs(excluding anti-TNF drug costs) decreased significantly from pre-index costs compared with RA non-TNF user costs. Additionalanalyses using clinical and quality-of-life measures are neededto determine the effectiveness of anti-TNF therapies.

IMPACT OF BOTULINUM TOxIN IN THETREATMENT OF REFRACTORY MIGRAINE HEADACHESIN A MANAGED CARE ORGANIzATIONMitchell MP,* Schaecher K, Cannon HE, Speckman MH. SelectHealth,4646 West Lake Park Blvd. Ste. N3, Salt Lake City, UT 84120;[email protected], (801) 442-5569

iNtRODUCtiON: Migraine headaches are a common conditionaffecting 6% of men and 15% to 17% of women in the UnitedStates. Migraines are one of the most common reasons for



patients to seek care with providers but only 3% to 5% ofthem received preventive therapy. Despite treatment withvarious preventive medications regimens, some patients failto gain adequate migraine relief. In recent years, botulinumtoxin has been suggested to be effective in the treatment ofmigraine for a select population. After a review of the litera-ture, the health plan created a medical policy and preautho-rization coverage policy that permits the use of botulinumtoxin in the treatment of migraines for patients who fail atleast 3 different acute treatment therapy classes and 4 differ-ent preventive medication classes. Neurology consultation isalso required.OBjeCtives: The primary objective of this study is to evaluatethe impact of botulinum toxin therapy on quality of life mea-

sures evaluated by direct member survey results. Secondaryobjectives include evaluating the impact of therapy on spe-cific migraine-related medications and overall medical andpharmacy costs pre- and postbotulinum toxin therapy.MethOD: The health system’s electronic medical recordsystem was used to identify and evaluate members witha billing code for migraine or headache by a neurologist.These members were then queried for the use of botulinumtoxin. More than 50 members were sent a “MedicationImpact Questionnaire for Botulinum Toxin Treatment.”Symptomatic improvement was assessed using a 5-pointLikert scale response to 6 questions. Areas assessedincluded headache severity, headache frequency, rescuemedications use, productivity/absenteeism, recreational


FIGURE 1 Overall Quality of Life Measures

0%

10%

20%

30%

40%

50%

60%

70%

80%

Res

pon

seR

ate

Respective MeasureNo or Little Improvement Moderate to Extreme Improvement

FIGURE 2 Individual Questions

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Little Improvement

No Improvement

Quite a bit of Improvement

Moderately Improved

Extremely Improved

HeadacheFrequency

HeadacheSeverity

Need to UseAcute Headache(Oral) Medications

Your RecreationalActivities

Work Productivity& Absence

Your Enjoymentof Life


activities, and life enjoyment. Medical and pharmacy claimswere analyzed from February 1, 2003 to March 31, 2007to evaluate the utilization patterns of botulinum toxin andmigraine-related medications. Members were pooled duringthe 4-year time frame to compare utilization patterns within18 months prior to starting therapy and 18 months afterstarting therapy.ResUlts: Surveys were sent to 54 members; 34 completedsurveys were returned. The majority of members reportedmoderate to extreme improvement overall (73%), with fewermembers reporting little or no improvement (27%). The aver-age cost of migraine-related medications for botulinum-toxin-treated members, through the pharmacy benefit increasedfrom $479.29 per member per quarter (PMPQ) to $723.29PMPQ. Total migraine-related prescriptions were similar formembers before and after receiving botulinum, 1,078 and1,099 respectively. The number of acute-treatment-relatedmedications increased slightly from 682 to 721. The com-bined medical and pharmacy expense increased for membersbefore and after received botulinum toxin, $2,017.37 PMPQ to$3,089.40 PMPQ respectively.CONClUsiON: Member survey results showed overall improve-ment according to the “medication impact questionnaire forbotulinum toxin treatment.” However, botulinum toxin treat-ment did not decrease utilization of migraine-related medica-tions or the overall medical and pharmacy expense for treatedmembers.

IMPACT OF VISION LOSS IN MEDICAREBENEFICIARIES WITH GLAUCOMABramley T,* Walt JG, Chiang TH. Xcenda, 1528 Preston St., Salt LakeCity, UT 84108; [email protected], (801) 983-6784

iNtRODUCtiON: Previous research demonstrated an associationbetween vision loss (VL) and higher costs plus increased risk ofdepression, injury, and institutional care in a general Medicarepopulation.OBjeCtive AND PURPOse: To assess the impact of VL in Medicarebeneficiaries (MBs) with glaucoma on costs and outcomes.MethODs: A retrospective cohort design of MBs diagnosedwith glaucoma with and without VL was used to evaluate theassociation of VL on annual costs plus the risk of depression,injury, accidents, and institutional care. The study popula-tion was obtained from the 5% analytical sample of MBfrom 1999-2004. Inclusion criteria were glaucoma diagnosis(International Classification of Diseases, Ninth Revision code365.xx), aged > 64 years, and not enrolled in a health main-tenance organization. Patients were separated into 4 visionloss categories: (1) no VL noted, (2) moderate VL, (3) severeVL, and (4) blindness. Outcomes of interested included costs,incident depression, injury, and institutional care. Costswere modeled using log-linear regression, and remaining

outcomes were modeled using logistic regression. All modelswere adjusted for age and gender.ResUlts: A total of 181,922 MB met the inclusion criteria.VL was noted in 7.9% of the sample (4.3% moderate VL,1.9% severe VL, and 1.7% blindness). Average annual costswere $6,782 for no VL, $11,054 for moderate VL, $12,914for severe VL, and $15,545 for blindness. Patients withany VL had 54.9% higher costs as compared with patientswithout VL (P < 0.0001). Patients with VL were significantlymore likely to develop depression (odds ratio [OR] = 1.89,95% confidence interval [CI]= 1.78-2.00) and had a higherrisk of injury (OR = 1.50, 95% CI = 1.41-1.58) and institu-tional care (OR = 2.41, 95% CI = 2.28-2.55) than patientswithout VL.CONClUsiONs: Vision loss in MB with glaucoma results in high-er costs and greater risk of depression, injury, and institutionalcare. Prevention of glaucoma progression and consequent VLwould likely improve clinical outcomes and reduce costs.

INCREASED HEALTH CARE UTILIzATIONFOLLOWING COLECTOMY IN ULCERATIVE COLITISThompson H, Meissner B, Dabbous O, Tang B, Arjunji R, Rahman M.Ahmad BN.* Centocor, Inc., 800 Ridgeview Dr., Horsham, PA 19044;[email protected], (215) 325-4237

PURPOse: To examine health care resource utilization in ulcer-ative colits (UC) patients following colectomy.MethODs: A retrospective analysis was conducted usingmedical and pharmacy claims from the PharMetrics data-base between January 1, 2000 and June 30, 2005. Patientswere required to have 2 distinct claims for UC (InternationalClassification of Diseases, Ninth Revision code 556.x) and werelimited to those who had a Current Procedural Terminology(CPT) code indicating colectomy (44140-44160), and a diag-nosis of UC prior to that date. The study design consisted of a12-month pre-colectomy period and 12-month post-colectomyperiod. Continuous enrollment was required for the entire2-year period. Health care resource utilization was evaluated12 months before and 12 months after the colectomy date.The outcomes of interest included health care encounters forthe following levels of care: inpatient, outpatient, emergencyroom, physician, laboratory, and drug costs. Basic populationcharacteristics were also examined including demograph-ics and overall patient comorbidity burden (Deyo-CharlsonComorbidity Index).ResUlts: A total of 411 patients with UC who had a claimfor colectomy were included in the analysis. Over half of thepatients were males (51.7%) and the mean age was 46 years.The mean Deyo-Charlson Comorbidity Index score was 4.4.Total utilization of services increased following colectomy,including inpatient encounters and outpatient encounters, allat significant levels (P<0.05).



CONClUsiONs: Health care utilization increased during the12-month period following colectomy, driven by increasesin inpatient and outpatient visits. Additional analyses areneeded to determine the extent of these services and rea-sons for increased service utilization.

MEDICAL SERVICE AND PRESCRIPTION DRUGCHARGES BEFORE AND AFTER INITIAL DIAGNOSISAMONG MANAGED CARE PATIENTS WITH CONSTIPATIONMitra D, Baran RW,* Davis KL. Takeda Global Research andDevelopment, One Takeda Pkwy., Deerfield, IL 60015;[email protected], (224) 554-6029

iNtRODUCtiON: The cost burden to health care payers asso-ciated with patient constipation is unclear. The change incharges for medical services and prescription drug utiliza-tion during a 12-month period before and after initial diag-nosis for patients with constipation and matched controlswas evaluated.MethODs: Health care claims from a large U.S. health plan(i3 Innovus) were retrospectively analyzed. Patients with≥ 1 constipation diagnosis (International Classification ofDiseases, Ninth Revision code 564.0x) between January 1,2003 and December 31, 2005 (N = 48,585), and demograph-ically matched (1:2 ratio) controls without constipation(N = 97,170 were identified). Index date was the date 3months prior to the first observed constipation diagnosis.For controls, index date corresponded to the respectivematch in the constipation group. All patients had ≥ 12months of benefits eligibility pre- and post-index date.Mean charges are reported.ResUlts: Total health care charges per patient with constipa-tion were $9,305 in the 12 months prior to index date, com-

pared with $17,799 in the 12 months following (+$8,494;P < 0.0001). Total charges per patient for controls were $5,967pre-index and $7,151 post-index (+$1,183; P < 0.0001). Thelargest pre-to-post difference in charges for the constipationcohort was for inpatient admissions ($2,341 vs. $5,845; P <0.0001). Prescription charges were $352 higher per patientin the post-index period for the constipation cohort versus$134 higher for controls (both P < 0.0001). After controllingfor additional covariates (gastrointestinal-related comor-bidities, cancer, opioid use, and Charlson ComorbidityIndex), multivariate regression analyses demonstrated thattotal charges per patient with constipation remained sub-stantially higher (+$3,664; P < 0.0001) post-index versuspre-index. Total charges for controls were $701 higher perpatient post-index after controlling for additional variables(P < 0.0001).CONClUsiONs: Health care charges for patients with consti-pation are significantly higher following initial diagnosis,with a larger pre-to-post difference compared with controls.Institutional costs are primary drivers for constipationexpenditures. Current standards of care may not be suffi-cient to reduce costs associated with constipation.

A MULTIDISCIPLINARY APPROACH TO PHYSICIANAND PATIENT EDUCATION ON ANTIBIOTIC PRESCRIBING

Arensdorf L, Davis M, Dohm J,* Knisley W, L’Estrange J, Richards S,Szczotka A. Catalyst Rx, 666 Grand Ave., Suite 900, Des Moines, IA50309; [email protected], (515) 558-6017

OBjeCtive AND PURPOse: To analyze primary care physi-cian acceptance and prescribing habits through a multi-disciplinary initiative around proper antibiotic prescribingeducation including distribution of patient-oriented coldcare kits. Program objectives were analyzed through directphysician satisfaction surveys and retrospective analysis ofantibiotic prescribing patterns between baseline and com-parator periods.MethODs: Both unnecessary prescribing and patient demandare 2 factors that can drive inappropriate antibiotic use. Amultidisciplinary collaborative effort between a statewidefamily practice association, commercial insurer, and phar-macy benefits manager was developed to provide physi-cian education and to distribute “patient cold-care kits”containing an over-the-counter decongestant, cough drops,and tissue packets to primary care providers in Iowa andSouth Dakota. The patient cold-care kits were distributedto patients by their physicians during the 2006-2007 coldseason.ResUlts: Approximately 20,000 patient cold-care kitswere distributed to physicians in Iowa and South Dakota.Physician satisfaction surveys reported a high acceptance


TABLE Mean Resource Cost and UtilizationPre- and Post-colectomy

VariablePre-colectomy

M (SD)Post-colectomy

M (SD) P Value

Total healthcare visits

Inpatientencounters

Outpatientvisits

26.6 (19.3) 39.4 (33.6)

1.8 (1.7)

19.4 (24.9)

0.9 (1.1)

8.7 (10.9)

Emergencyroom visits

Physicianvisits

Laboratoryvisits

0.8 (1.4)

13.9 (11.7)

2.1 (3.3)

0.9 (1.6)

14.9 (13.9)

2.2 (4.3)

< 0.0001

< 0.0001

< 0.0001

0.2583

0.1595

0.7790


rate by physicians and a significant majority (76% of surveyresponders) reported the cough and cold kits helped thephysician avoid writing unnecessary prescriptions. Themultidisciplinary approach, including the statewide fam-ily practice organization, assisted with their acceptance.Physicians reported a high rate of patient acceptance andpositive perception of the cold-care kits. Final retrospectiveanalysis of the antibiotic prescribing patterns is pendingcompletion of the 2006-2007 cold season, but prelimi-nary results from the initial comparator periods indicate adecrease in overall antibiotic utilization.CONClUsiONs: A multidisciplinary approach to proactivephysician education around appropriate antibiotic prescrib-ing was well-accepted from the primary care physician’sperspective. Supportive assistance, including the provisionof patient cold-care kits was also well-accepted and contrib-uted to the program’s success. Overall antibiotic prescrib-ing, as compared with baseline periods, is expected to showa reduction in antibiotic utilization to comparator periods.

ONE-YEAR COSTS OF ISCHEMIC HEART DISEASEAMONG PATIENTS WITH ACUTE CORONARY SYNDROMES:FINDINGS FROM A MULTI-EMPLOYER CLAIMS DATABASEMenzin J,* Wygant G, Hauch O, Friedman M, Jackel JL. BostonHealth Economics, 20 Fox Rd., Waltham, MA 02451;[email protected], (781) 290-0808

BACKGROUND: Acute coronary syndromes (ACSs) are life-threatening disorders often requiring intensive medicalmanagement or invasive cardiovascular procedures. Limiteddata exist on the costs of ischemic heart disease (IHD)among patients with ACS following hospital discharge.OBjeCtive: To analyze IHD-related employer expendituresover 1 year for patients with ACS.MethODs: In this retrospective cohort study, the MedstatMarketScan Database was used to select patients withan ACS diagnosis (International Classification of Diseases,Ninth Revision, Clinical Modification [ICD-9-CM] codes 410and 411.1) on a hospital claim between January 2001 andDecember 2002. Patients who were under age 35 years orhad an IHD (ICD-9-CM codes 410-414) hospitalizationin the prior 12 months were excluded. All analyses weredescriptive in nature. Costs were updated to 2005 dollars.ResUlts: We identified 17,243 patients with an initial hos-pitalization for ACS during the study period. Mean patientage was 55.7 (SD = 6.8) years, 67.3% were male, and 47.8%had a revascularization procedure during their initial hospi-talization. Length of stay for the initial hospitalization aver-aged 4.4 days (median = 3.0; interquartile range [IQR] = 2.0-5.0), and expenditures averaged $22,872 (median = $14,088;IQR = $6,902-$28,548). Twenty-one percent of patients wererehospitalized within 1 year after discharge from the initial

inpatient stay with an IHD diagnosis. The costs of rehospi-talization for these patients averaged $26,233. In the yearfollowing initial ACS hospitalization, 52% of patients wereprescribed antiplatelet or anticoagulant medications, and92% of patients were prescribed lipid-lowering, antihyper-tensive, or antiarrhythmic drugs. IHD-related health careexpenditures during the year after the initial hospitaliza-tion averaged $9,178 (median = $2,811; IQR = $913-$7,424);approximately 66% of these costs were due to rehospital-ization. Total 1-year post-discharge costs averaged $32,050(median = $21,761; IQR = $10,761-$40,853).CONClUsiONs: In this employer group population, the costs ofpost-discharge care, especially readmissions, were substan-tial. In future studies, researchers should evaluate the impactof improved patient management on post-discharge costs.

REAL-WORLD ADHERENCE RATES OF CHRONIC MYELOIDLEUkEMIA PATIENTS TO HIGHER DOSES OF IMATINIBSun SX,* Fincher CL, Wang J, Lee KY, Buchner D. Walgreens HealthServices, 1415 Lake Cook Rd., MS L444, Deerfield, IL 60015;[email protected], (847) 964-6928

BACKGROUND: Imatinib (Gleevec) is an oral tyrosine kinaseinhibitor for the treatment of patients diagnosed withchronic myeloid leukemia (CML). The overall adherencerate of imatinib has been reported at 75% using pharmacyclaims. One of the National Comprehensive Cancer Network(NCCN) treatment recommendations for these patients ishigher doses of imatinib for patients showing signs of dis-ease progression or inadequate response.OBjeCtive: To estimate real-world adherence rates amongCML patients receiving specified doses of imatinib.MethODs: Study population includes patients with CMLwho filled imatinib prescriptions (< 400 mg, 400 mg to< 600 mg, 600 mg to < 800mg and ≥ 800 mg) at a nationalretail pharmacy chain from August 1, 2006 to March 31,2007. Inclusion criteria were as follows: (1) 2 prescriptionsor 60 days supply of the study drug during the study period;(2) age ≥ 18 years. Adherence is measured using the medica-tion possession ratio (MPR), calculated by taking the totalnumber of days of medication supplied divided by the num-ber of days from index date to the end of the study period.ResUlts: A trend across the imatinib dose categories showsdecreasing adherence as the dose of imatinib increases. Theadherence rate of imatinib < 400 mg, 400 mg to < 600 mg,600 mg to < 800mg and ≥ 800 mg was 66.90%, 65.77%,52.13%, 48.11%, respectively. A significant difference wasfound between > 400 mg to <600mg vs. > 600 mg to <800mg (P < 0.0001). At the higher doses (> 600 mg), the adher-ence rate was 50.56%.CONClUsiONs: Dose escalation of imatinib to > 600 mgappears to be associated with a lower patient adherence



rate. Clinical decision makers may want to take this intoconsideration when treating CML patients at doses of ima-tinib > 600 mg.

SLEEP DISRUPTION AND INSOMNIA: RELATIONTO WORk PRODUCTIVITY AND TREATMENT USERosekind M, Brandt S, Mallis M,* Seal B, Gregory K, Balkrishnan R.*The Ohio State University, College of Pharmacy, 500 W 12th Ave.,136-C, Columbus, OH 43210; [email protected], (614) 292-6415

iNtRODUCtiON: The impact of insomnia on presenteeism inthe real world is poorly understood. The objective of thisstudy was to explore how employee-reported sleep disrup-tion translated into workplace productivity outcomes in adiverse work population and related treatment use.MethODs: Three U.S.-based companies in different indus-tries participated by completing a 55-item, anonymous,online survey. Respondents were classified according tothe Diagnostic and Statistical Manual of Mental Disorders,4th ed., text revision minimum criteria for “primary” and“secondary” insomnia and International Classification of SleepDisorders minimum criteria for insufficient sleep syndrome(ISS). The remaining respondents were classified as either“at-risk” (reported a medical, psychological, or sleep condi-tion that precluded insomnia or ISS) or “good sleep” (did notmeet criteria for any other group). Workplace productivitywas measured using the Work Limitation Questionnaire(WLQ). Statistical comparison on the WLQ index score andtreatment use outcomes were made between sleep groupsusing analysis of variance and chi-square tests.ResUlts: There were a total of 3,471 respondents (39.6 ±11.1 years; 55.5% male), with 46.8% (n = 1,623) reportinginsomnia symptoms. These included 18.8% (n = 305) whoreported induction difficulties only, 27.4% (n = 445) whoreported maintenance problems only, and 53.8% (n = 873)who reported a combination of both. A total of 9.0% (n =312) respondents met the diagnostic criteria for insomnia(59.3% primary, 40.7% secondary) and 5.6% (n = 195) metthe criteria for ISS. The remaining respondents included38.4% (n = 1,334) “at-risk” and 47.0% (n = 1,630) “goodsleep.” The insomnia group reported the greatest (P < 0.05)percent of productivity loss (5.9%) compared with the at-risk (4.5%) and good sleep (2.4%) groups, though similar tothe ISS (5.2%) group. The insomnia group (29.5%) reportedthe most (P < 0.0001) insomnia-specific prescription usecompared to ISS (7.2%), at-risk (13.4%) and good sleepgroups (4.4%).CONClUsiONs: A large number of workplace respondentsreported insomnia symptoms, although a small number metthe diagnostic criteria. Insomnia was significantly relatedto reduced work-productivity. The insomnia group reportedthe most prescription use.

TREATMENT OF RELAPSED MYELOMA: A BUDGETIMPACT MODEL COMPARING SINGLE AGENTBORTEzOMIB WITH COMBINATION LENALIDOMIDEAND HIGH-DOSE DExAMETHASONEFullerton DS,* Huleatt H,* Marantz JL, Huang H, Veljkovic J,Trautman H.* Strategic Pharmacy Innovations, 4910 Purdue Ave. NE,Seattle, WA 98105; [email protected], (206) 369-7921

BACKGROUND: Despite recent advances, multiple myelomaremains incurable; most patients eventually relapse. Twonovel therapies, bortezomib and combination lenalido-mide plus high-dose dexamethasone (len/dex) have beenapproved for relapsed myeloma patients.OBjeCtive AND PURPOse: A budget impact model was devel-oped to evaluate the direct costs (drugs, administration,hydration, lab tests, treatment of adverse events [AE]) for 2common second-line therapies: single agent bortezomib (IVbolus) and combination len/dex (oral).MethODs: A managed care payer perspective was used. Themedian overall survival for both therapies in pivotal clinicaltrials (both trials in patients with a median of 2 prior thera-pies) was similar: 29.8 months for bortezomib (APEX trial),and 29.6 months for len/dex (MM-009 trial). The mediandurations of treatment were 18 weeks (6 cycles) for bort-ezomib and 44 weeks (11 cycles) for len/dex. The base casecalculated costs for the median durations of each treatment:bortezomib at 15% with 20% patient coinsurance; and len/dex at average wholesale price (AWP)-15% with 20% patientcopay. Number of office visits for bortezomib was 24, and11 for len/dex. The costs for managing major AE reportedin these trials were also included; unit costs were obtainedfrom the published literature.ResUlts: Total costs for single agent bortezomib weresubstantially less than for len/dex. (As a reference, drug


Drug costs

BortezomibLenalidomide/

Dexamethasone

$6,774

$23,697

$4,723

$35,194

TABLE Cost Per Patient for TreatingRelapsed Multiple Myeloma

$3,204

$59,962

$5,936

$69,102

Medical costs*

AE treatment costs

Total (per patient)

*Administration, office visits, lab tests, prophylaxis for deep vein thrombosis (DVT),pulmonary embolism (PE), and herpes zoster.AE = adverse events.

Variable


costs for thalidomide/dexamethasone, the original immuno-modulatory therapy, would be $45,403.)CONClUsiONs: This budget impact model suggests that use ofbortezomib, relative to len/dex, offers a cost saving opportu-

nity for managed care organizations (MCOs) while achievingcomparable survival in relapsed myeloma patients.


FIGURE One-Way Sensitivity Analyses (Tornado Diagrams)

AE = adverse event; DVT-PE = deep vein thrombosis pulmonary embolism.

Per-Patient Treatment Costs

Per-Patient Treatment Costs


Managed Care Pharmacy Residencies,Fellowships, and Other Programs

RESIDENCIES, FELLOWSHIPS, AND OTHER PROGRAMS

The following is a partial list of available managed carepharmacy residency and fellowship programs and otherprograms compiled as of August 2007. The residencies

listed were submitted by AMCP members in response to AMCP’scall for residency program listings. This is not a comprehen-sive list of all available programs. AMCP provides it solely as aservice to its readers. This list does not imply AMCP’s endorsementof any particular program nor does AMCP guarantee the avail-ability of any of the programs listed. AMCP does not assumeresponsibility for any errors that may appear in these listings. Ifyou are aware of additional residency and fellowship programsnot listed here, please contact AMCP at (800) TAP-AMCP.

nn AMeriCAn HeAltH CAreClinical therapeutics/Managed Care PharmacyAccredited: AMCP/American Society of Health-

Systems Pharmacists (ASHP)Length of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: OpenStarting Date: July 1Estimated Stipend: $43,000 and upOnsite Interview: YesEducational/Special Requirements: PharmD with Californiapharmacist license or eligibility for licenseFringe Benefits: Medical, dental, vision, holidays, vacation, andattendance at national conference(s)Special Features: Activities the resident will be involved ininclude (but are not limited to) P&T committee participationand presentations, formulary management and review, one-on-one physician correspondence on evidence-based medicinewith current clinical studies reviewed and presented, focus-ing on actual patients that may benefit from this information,new drug review and its placement with available therapies,clinical participation and set-up, client summary report write-upand delivery, participation in various education conference andclinical studies.Contact Information:Nazly WesternoffAmerican Health Care2217 Plaza Dr., Ste. 100Rocklin, CA 95765(916) 773-7227(916) 773-7210 (fax)[email protected]

nn Blue Cross And Blue sHield of AlABAMAManaged Care PharmacyAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 15Starting Date: July 1 (flexible)Estimated Stipend: $34,000Onsite Interview: YesEducational/Special Requirements: National Matching Ser-vices (NMS) Code Number: 201514; PharmD or equivalentexperienceFringe Benefits: Paid vacation, personal holiday leave, health/dental insurance, no on-call responsibilities, no weekends orholidaysSpecial Features: The program provides the resident with theopportunity to experience a true integrated medical system,including medical and pharmacy claims. The areas of focus willinclude pharmaceutical care, drug information, formularymanagement, clinical program management, disease statemanagement and outcome studies, Specialty Pharmacy, andMedicare Part D. The resident also will complete a researchproject suitable for publication. This program will incorporatepersonal, communication, and time management skills.Contact Information:Jerry Wong, PharmD, MBA, Residency DirectorBlue Cross and Blue Shield of Alabama450 Riverchase Parkway EastBirmingham, AL 35244(205) 220-6526(205) 220-2939 (fax)[email protected]

nn Blue Cross And Blue sHield of neBrAskAManaged Care PharmacyAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of Nebraska Medical CenterApplication Deadline: January 11Starting Date: June 30Estimated Stipend: $40,000Onsite Interview: RequiredEducational/SpecialRequirements: PharmD degree from anAccreditation Council for Pharmacy Education (ACPE)-accredited



college of pharmacy). Licensed pharmacist in the United Statesor eligibility for licensure (successful candidate must be fullylicensed at the start of residency). Application requirementsinclude: application, writing sample, 3 professional letters ofrecommendation and on-site interview with short formalpresentation.Fringe Benefits: 10 days paid vacation, holidays, healthinsurance, paid travel and registration to AMCP EducationalConference and Annual MeetingSpecial Features: The Blue Cross and Blue Shield of Nebraskaresidency will offer exposure to various aspects of managed carepharmacy through health plan and PBM exposure as well asdirect patient care through clinical rotations. The residencywill offer participation and exposure to the following areas:pharmacy benefit design, utilization management, formularymanagement, pharmacy trend management, drug information,health economic/outcomes research, pharmacy benefit manage-ment, disease state management quality assurance initiatives.This unique program also allows the resident the option toparticipate in teaching or didactic coursework through theUniversity of Nebraska Medical Center.Contact Information:Clint Williams, Director of PharmacyBlue Cross and Blue Shield of Nebraska7261 Mercy Rd.Omaha, NE 68180(402) 390-1853(402) 548-4683 (fax)[email protected]

nn Blue sHield of CAliforniAManaged Care Pharmacy systemsAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of California, San FranciscoApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $46,000Onsite Interview: YesEducational/Special Requirements: PharmD degree from anaccredited school of pharmacy, completion of a managed carepharmacy practice or a pharmacy practice residency, 3 letters ofrecommendation, letter of intent, and on-site interviewFringe Benefits: Health/dental/vision benefit, 20 days of paidtime off including professional leave (with travel allowances)and 9 holidays, no on-call responsibilitiesSpecial Features: Residents participate in the development ofmedication policies, pharmacy benefits, and population-baseddisease management, pharmaceutical contracting support/analy-sis, and quality improvement. This program teaches residents toconceptualize, integrate, and transform accumulated experiences

and knowledge into improved drug therapy for patients.Contact Information:Tara Abrams, Senior Clinical Pharmacist, Quality ImprovementBlue Shield of California Pharmacy Services50 Beale St., 22nd FloorSan Francisco, CA 94105(415) 229-6424(415) 229-6011 (fax)[email protected]

nn CAreMArkManaged Care PharmacyAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 1 position in TexasAffiliation: NoneApplication Deadline: January 8Starting Date: July 2Estimated Stipend: $38,000Onsite Interview: YesEducational/Special Requirements: PharmD with experiential orinternship-based experience in the managed care/PBM industryFringe Benefits: Comprehensive medical, dental and lifeinsurance plan, 2 weeks paid vacation, holidays, employee stockpurchase program, flexible spending program, travel budgetSpecial Features: Caremark’s general managed care residencyprogram is rotationally based that includes both on-site andoff-site learning experiences. This residency will allow theresident to be involved in the day-to-day operations of apharmacy benefit management company. The resident will beoffered the opportunity to experience a variety of different areasincluding the formulary management process, medical affairs,client management, health plan operations, research, diseasestate management, clinical program development, and specialtypharmacy.Contact Information:Melissa Jay, Client Benefits Clinical, ManagerCaremark750 West John Carpenter Fwy.Irving, TX 75039(469) 524-5832(469) 524-5858 (fax)[email protected]

nn CAreMArk, inC.Managed Care specialty-Analytics and outcomesAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of Illinois at Chicago;

Midwestern University-ChicagoCollege of Pharmacy



Application Deadline: January 11Starting Date: July 7Estimated Stipend: $38,000Onsite Interview: YesEducational/Special Requirements: PharmD with experiential orinternship-based experience in the managed care/PBM industryFringe Benefits: Comprehensive medical, dental, and lifeinsurance plan; 2 weeks paid vacation; holidays; employee stockpurchase program; flexible spending program; travel budgetSpecial Features: CVS Caremark is the #1 provider ofprescriptions and related healthcare services in the nation. TheCompany fills or manages more than 1 billion prescriptionsannually. Through its unmatched breadth of service offerings,CVS Caremark is transforming the delivery of healthcare ser-vices in the United States. CVS Caremark is uniquely positionedto effectively manage costs and improve healthcare outcomesthrough its 6,200 CVS/pharmacy stores; its pharmacy benefitmanagement, mail order, and specialty pharmacy division, Care-mark Pharmacy Services; its retail-based health clinic subsidiary,MinuteClinic; and its online pharmacy, CVS.com. The Analyticsand Outcomes Residency will provide the resident a uniqueopportunity to work on initiatives that foster proactive manage-ment of pharmaceutical and overall healthcare costs. It offers theability to work with large data sets and perform various pharma-ceutical cost analyses such as plan design modeling, formularyanalysis and clinical outcomes. The resident will have theopportunity to interact directly with clients, consultants andvarious other benefit providers as well as internal areas todevelop analytic tools and methods to support all customers.While the focus is on analytics, the resident will be exposed tovarious areas in pharmacy benefit management such as clinicalprogram development and implementation, operations, sales,account management, clinical sales support, marketing andcommunications, trade relations, pharmaceutical services, andtherapeutic services.Contact Information:Barry Kennick, Director, Analytics and Outcomes,Residency CoordinatorCaremark, Inc.2211 Sanders Rd.Northbrook, IL 60062(847) 559-5212(847) 559-5475 (fax)[email protected]

nn CliniCAl PHArMACology serviCes, inC.Ambulatory Care/Clinical researchAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: February 1

Starting Date: June 1Estimated Stipend: $38,000Onsite Interview: YesEducational/Special Requirements: Not listedFringe Benefits: Sponsorship to Professional Meeting andSouthwestern Residency ConferenceSpecial Features: Not listedContact Information:Daniel Buffington, PharmD, MBA, DirectorClinical Pharmacology Services6285 E. Fowler Ave.Tampa, FL 33617(813) 983-1500(813) 983-1501 (fax)[email protected]://www.cpshealth.com

nn CliniCAl PHArMACy serviCesManaged Care Pharmacy PracticeAccredited: ASHP/AMCPLength of Program: 12 monthsNumber of Positions: 4Affiliation: University of Massachusetts

Medical SchoolApplication Deadline: January 18Starting Date: July 1Estimated Stipend: $38,500Onsite Interview: RequiredEducational/Special Requirements: PharmD degree; eligibil-ity for licensure in Massachusetts, valid driver’s license, letterof intent including goals, college transcripts, curriculum vitae,3 letters of recommendation, personal on-site interviewFringe Benefits: Health, dental, vision, disability, life insurance,earned time accrual for vacation, 13 state/federal holidays, officespace with computer, travel/conference allowance (ASHPMidyear Clinical Meeting, Eastern States Resident & PreceptorsConference)Special Features: After orientation to the department, theresident will begin a series of longitudinal rotations andother activities designed to meet the goals and objectivesof the Commonwealth Medicine managed care pharmacyresidency program. The resident will work with multipleprogram directors and clinical pharmacists in order to gaina thoroughunderstandingofclinicalmedicationmanagementandcost-containment strategies. Activities will include prepar-ing and presenting monographs for medication/class reviews,participating in the planning and roll-out of clinical pharmacyinitiatives, and precepting pharmacy students on clinicalrotations.Contact Information:Jake Nichols, Director of Clinical AffairsCommonwealth Medicine



Clinical Pharmacy Services333 South St.Shrewsbury, MA 01545(508) 421-6168(877) 208-7428 (fax)[email protected]

nn Coventry HeAltH CAre of kAnsAs, inC.Health Plan Managed Care PharmacyAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of Missouri-Kansas City

(UMKC)Application Deadline: January 4Starting Date: July 1Estimated Stipend: $40,000Onsite Interview: YesEducational/Special Requirements: PharmD degree from anACPE-accredited College of Pharmacy; licensed pharmacist inthe United States or eligibility for licensure (successful candidatemust be fully licensed at the start of residency); application; letterof intent; curriculum vitae; writing sample; official transcripts;3 professional letters of recommendation; on-site interview withshort formal presentation in Kansas CityFringe Benefits: 2 weeks paid vacation, holidays, medicaland dental insurance, paid travel and registration to AMCPEducational Conference, AMCP Annual Meeting, ASHP MidyearMeeting & FMCP programSpecial Features: Residency opportunities in all managed carecore competencies: pharmacy benefit management, utilizationmanagement, formulary management, clinical consultationservice, drug information, new technologies assessment, providernetwork relations, Medicare plan interventions, disease statemanagement, health and wellness initiatives, quality assurance/improvement activities, marketing and sales, contracting, healtheconomics/outcomes, rotations with pharmaceutical indus-try, teaching experience through UMKC, PharmD experientialrotation oversightContact Information:Diana Toe, Regional Clinical PharmacistCoventry Health Care of Kansas, Inc.8320 Ward Pkwy.Kansas City, MO 64114(866) 795-3995(866) 795-3992 (fax)[email protected]://www.cvty.com

nn grouP HeAltH CooPerAtiveManaged Care Pharmacy PracticeAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 10Starting Date: July 1Estimated Stipend: $43,800Onsite Interview: YesEducational/Special Requirements: PharmD or equivalentexperienceFringe Benefits: Full medical coverage ($35 per month paid bythe employee) and dental coverage (cost varies depending onplan chosen by employee) for the resident, 7 days of vacation.Paid registration and some fees to attend professional meetingsis provided.Special Features: The residents are trained in the role of thepharmacist in the development and implementation of clinicalpractice guidelines, formulary development and management,as well as drug use policy development. In addition, residentsare trained to function as leaders in implementing pharmaceuti-cal care plans for specific patients in an integrated health planand delivery system setting.Contact Information:Jim Carlson, DirectorClinical Pharmacy and Health Plan ServicesGroup Health Cooperative12400 E. Marginal Way S.Seattle, WA 98168(206) 901-4425(206) 901-4410 (fax)[email protected]://www.ghc.org/about_gh/employ/rxresidency.jhtml

nn HArvArd vAnguArd MediCAl AssoCiAtesPharmacy Practice with emphasis in Managed CareAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: Massachusetts College of Pharmacy

and Health SciencesApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $32,000Onsite Interview: YesEducational/Special Requirements: BS in pharmacy or PharmDFringe Benefits: Comprehensive medical plan, 2 weeks paidvacationSpecial Features: Academic appointment-adjunct instructor inpharmacy practice



Contact Information:Kathy Zaiken, PharmDMassachusetts College of Pharmacy & Health Sciences179 Longwood Ave.Boston, MA 02115(617) 732-2740(617) 732-2244 (fax)[email protected]://www.mcphs.edu

nn HeAltH net PHArMACeutiCAl serviCesManaged Care Pharmacy PracticeAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of the Pacific; University of

California at San FranciscoApplication Deadline: January 15Starting Date: July 1Estimated Stipend: 50,000Onsite Interview: RequiredEducational/Special Requirements: Graduate of an ACPE-accredited college of pharmacy, licensed pharmacist oreligible for licensure in the state of California, completedapplication form, letter of intent (not to exceed 500 words)summarizing applicant’s motivation for pursuing a residency inmanaged care and short-term and long-term career goals, currentresume or curriculum vitae, 3 letters of recommendation,1 official transcript sent directly from applicant’s school ofpharmacy, and completion of an on-site interviewFringe Benefits: Competitive residency stipend; full benefits asa Health Net associate including: paid holidays, medical/dental/pharmacy/vision coverage, paid time off, 401K program, healthclub reimbursement program; and support to attend variousprofessional meetingsSpecial Features: Health Net Pharmaceutical Services managesthe pharmacy benefits, drug spend, and clinical programs forthe health plans of Health Net, Inc. The managed care pharmacypractice resident will gain experience in formulary management,prior authorization, strategic benefit design, and pharmacyoperations; and will participate in Health Net’s national P&Tcommittee and clinical pharmacy advisory committee.Contact Information:Cathrine Misquitta, DirectorClinical Pharmacy ServicesHealth Net Pharmaceutical Services10540 White Rock Rd., Ste. 280Rancho Cordova, CA 95670(916) 463-9602(916) 463-9750 (fax)[email protected]

nn HeAltH PlAn of sAn JoAquinManaged Care Pharmacy PracticeAccredited: PendingLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of the Pacific, San Joaquin

General HospitalApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $45,000Onsite Interview: YesEducational/Special Requirements: PharmD from an ACPE-accredited college of pharmacy or equivalent experience,eligibility for California licesure, good academic standing,excellent written and verbal communication skillsFringe Benefits: Health, dental, vision, life, and disabilityinsurance available; vacation time allotted, professional traveland stipend available, no weekends or holidays, no staffingrequirements in a pharmacySpecial Features: The program is unique in providing abalanced exposure to institutional clinical practice, longitu-dinal ambulatory care practice as well as the operation of aMedicaid managed care health maintenance organization(HMO). The primary emphasis is placed on the application ofclinical skill on the development and implementation of medica-tion use management initiatives and policies, clinical programs,formulary management, pharmacoeconomic and outcomeassessment, drug information and effective communication. Theresident will be involved in classroom teaching and preceptingclerkship students from University of the Pacific.Contact Information:Allen Shek, Residency Program Director,Associate ProfessorHealth Plan of San Joaquin, University of the Pacific7751 South Manthey Rd.French Camp, CA 95231(209) 461-2209(209) 461-2409 (fax)[email protected]://www.hpsj.com/english/careers/pharmacy-intern.aspx

nn HeAltHPArtnersManaged Care PharmacyAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: CompetitiveOnsite Interview: YesEducational/Special Requirements: PharmD



Authors

Fringe Benefits: Health insurance, vacation, and holidaysSpecial Features: Travel/registration for 1 national meetingContact Information:Vyvy Vo, Clinical Pharmacy Program ManagerHealthPartners8170 33rd Ave. SouthMailstop 21111B(952) 967-5133(952) 883-5875 (fax)[email protected]://www.healthpartners.com

nn Henry ford HeAltH systeMManaged Care PharmacyAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: February 15Starting Date: July 1Estimated Stipend: CompetitiveOnsite Interview: YesEducational/Special Requirements: PharmD, pharmacy practiceresidency desirableFringe Benefits: Health care, 2 weeks paid vacation, travel to1 meetingSpecial Features: The resident will design system enhance-ments and participate in ongoing utilization management,disease management, and compliance intervention programs.He/she will participate in formulary management and designclinical indicationsofeffectiveness forguidelines.Theresidentwillformulate and answer a research question, using scientificprinciples, with a strong emphasis on outcomes, pharmacoeco-nomics, and quality-of-life research. Experiences will includeexposure to our HMO (Health Alliance Plan) and involvementwith the Center for Clinical Effectiveness, Health System studies,Quality Improvement center, and clinical pharmacy services.Direct patient care responsibilities in one of our ambulatoryclinics will be ongoing throughout the year.Contact Information:Vanita Pindolia, DirectorPharmacy Care ManagementHealth Alliance Plan2850 W. Grand Blvd., Tower 14, Ste. 200Attention: PharmacyDetroit, MI 48202(248) 443-8849(248) 443-8614 (fax)[email protected]

nn Horizon nJ HeAltHManaged Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: Horizon BCApplication Deadline: February 1Starting Date: July 1Estimated Stipend: $35,000Onsite Interview: YesEducational/Special Requirements: PharmD or equivalentexperience; eligibility for New Jersey state licensureFringe Benefits: Paid vacation, full medical/dental/retirementbenefitsSpecial Features: Medicaid managed care HMO, uniquefocus on government programs, pharmacy case management,formulary and disease state management, development of clinicalpolicies, outcomes research, assist with PharmD studentoversight, ambulatory care experience, professional develop-ment courses, attendance to at least one national conference.Contact Information:Jennifer Gauweiler, Pharmacy Clinical ManagerHorizon NJ Health210 Silvia St.West Trenton, NJ 08628(609) 538-0700(609) 538-1698 (fax)[email protected]

nn HuMAnA inC.Managed Care PharmacyAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 7Starting Date: July 1Estimated Stipend: $37,000Onsite Interview: YesEducational/Special Requirements: Graduate of an accred-ited school of pharmacy, PharmD preferred, minimum gradepoint average of 3.2 (on a 4.0 scale), and eligible for pharmacylicensureFringe Benefits: Health, dental, 401(k), 3 weeks vacation,2 floating holidays, relocation allowance, and travel expensespaid for 2 professional meetingsSpecial Features: Humana Inc., headquartered in Louis-ville, KY, is one of the nation’s largest publicly traded healthbenefits companies with over 11 million covered lives. Humanaoffers integrated health benefits for both medical and pharmacyto employer groups, government sponsor plans and indi-viduals. Humana’s residency program offers a broad range of



programmingwithin thepharmacymanagementdepartment.Theresidency will offer exposure to various aspects of managed carepharmacy within operations and management of the organiza-tion, formulary management, clinical strategy, network relations,trend management, industry relations/contracting, outcomesresearch and medication therapy management.Contact Information:Jane Stacy, Manager, Professional DevelopmentHumana Inc.500 W. Main St., 16th FloorLouisville, KY 40202(502) 580-1591(502) 508-1591 (fax)[email protected]

nn kAiser foundAtion HeAltH PlAnof tHe Mid-AtlAntiC stAtes, inC.Health Maintenance organizationAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $49,000Onsite Interview: YesEducational/Special Requirements: PharmD required, phar-macy licensure eligibility in DC, MD, or VAFringe Benefits: Medical benefits, selected holidays, sick, vaca-tion and education leave for ASHP Midyear Clinical Meeting andEastern States Residency ConferenceSpecial Features: In addition to direct patient care core rotations,the resident will assist in the development of new and innovativepharmacy services, conduct patient education classes, providecontinuing education programs for pharmacy staff members andphysicians, assist with teaching pharmacy students, participatein the Regional Pharmacy & Therapeutics Committee meetingsand complete several population-based projects.Contact Information:Amber Polk-Coleman, Residency Program DirectorKaiser Permanente Health Plan of the Mid-Atlantic States6525 Belcrest Rd.Hyattsville, MD 20904(301) 209-6114(301) 209-6204 (fax)[email protected]

nn kAiser PerMAnente-CAliforniA—Pgy2 residenCy in drug inforMAtionMedical Care/drug informationAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 3Affiliation: NoneApplication Deadline: January 11Starting Date: July 1Estimated Stipend: $70,000Onsite Interview: YesEducational/SpecialRequirements: PharmD, postgraduate year1 (PGY1) residency, excellent communication skills, eligible forCA licensure, 3 letters of recommendation. Per the rules forthe Resident Matching Program, this residency site agrees thatno person at this site will solicit, accept, or use any ranking-related information from any residency applicant.Fringe Benefits: Medical, dental, optical insurance, 10 daystime off, attendance at 1 pharmacy conferenceSpecial Features: This postgraduate year 2 (PGY2) specialtyresidency in drug information practice offers extensive trainingwithin a large, progressive drug information center. The residentwill gain knowledge, skills and experience responding toinquiries from health care professionals, the use and mainte-nance of our national pharmacy intranet site, and writingnumerous drug information publications. Teaching activitiesinclude precepting pharmacy students and PGY1 residents inour Inquiry Service and presenting formal lectures at localschools of pharmacy (USC, Western University). The residentwill participate in formulary management and attend regionaland local P&T committee meetings. Longitudinal experiencesand discussions in pharmacy outcomes research and dataanalysis, management activities and quality assurance take placethroughout the year.Contact Information:Mirta Millares, PharmD, FCSHP, FASHPKaiser Permanente12254 Bellflower Blvd., Ste. 106Downey, CA 90242(562) 658-3640(562) 658-3758 (fax)[email protected]://www.kaiserpharmacyresidency.org

nn kAiser PerMAnente ColorAdoManaged Care/Primary CareAccredited: Preliminary accreditation status receivedLength of Program: 12 monthsNumber of Positions: 6Affiliation: NoneApplication Deadline: January 11Starting Date: July 7



Estimated Stipend: $49,202Onsite Interview: YesEducational/Special Requirements: PharmD, postgraduateyear one (PGY1) residency and eligibility for licensure inColorado requiredFringe Benefits: Health insurance, paid sick and vacation leave,paid holidays, travel support to ASHP Midyear Meeting andWestern States Residency Conference, and online library andcomputer privilegesSpecial Features: This unique postgraduate year 2 (PGY2)residency provides the opportunity to acquire advanced knowl-edge and skill in ambulatory care pharmacotherapy in a managedcare environment. Core experiences include primary care,clinical pharmacy anticoagulation service (6,500 patients), and alongitudinal rotation in the clinical pharmacy cardiac riskservice (10,000 patients). Four elective rotations are available forin-depth exposure into disease state management (asthma/allergy, cardiology/heart failure, continuing care, endocrinology,oncology, infectious diseases, psychiatry, neurology, nephrology,and palliative care). A research project of publishable quality isrequired. Evaluation of quality and financial outcomes is empha-sized.Contact Information:Rachana Patel, Clinical Pharmacy SpecialistKaiser Permanente1375 East 20th Ave.Denver, CO 80205(303) 764-4479(303) 861-3668 (fax)[email protected]

nn kAiser PerMAnente MediCAl CAre ProgrAM—CentrAl vAlley AreAManaged Care Pharmacy PracticeAccredited: ASHP/AMCPLength of Program: 12 monthsNumber of Positions: 2Affiliation: Kaiser PermanenteApplication Deadline: January 14Starting Date: June 30Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Must be a graduate froman accredited school or college of pharmacy by June 30,2007, PharmD preferred, must meet all qualifications of licensurein California, must meet Kaiser Permanente’s employeerequirementsFringe Benefits: 7 paid holidays, medical/vision/dental,vacation/sick leave, paid educational travel opportunitiesSpecial Features: This program offers training in a variety ofpractice settings and provides opportunities to gain valuableclinical and administrative experience in a managed care

organization. The core experiences include direct patient care,business administration and management, population basedpharmaceutical care, and drug information. Residents partici-pate on the P&T Committee, serve as preceptors for pharmacystudents, and are an integral part of the pharmacy managementteam. Professional and career development is encouragedthroughout the residency.Contact Information:Ryan Taal, Drug Education CoordinatorKaiser Permanente Medical Care Program-Central Valley Area7373 West LaneAttention: Susan, 3rd Floor PharmacyStockton, CA 95210(209) 557-1145(209) 557-1180 (fax)[email protected]://kaiserpharmacyresidency.org/programs/mcCentralValley/

nn kAiser PerMAnente MediCAl CAre ProgrAM—inlAnd eMPire serviCe AreAgeneral Pharmacy PracticeAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Graduate of accreditedcollege of pharmacy, licensed or eligible for California licensure,pharmacy school transcript, 3 letters of recommendation, letterof intent, and curriculum vitaeFringe Benefits: 2 weeks paid vacation, health benefits includ-ing dental/optical, paid holidays, office space, reimbursementfor off-site experiencesSpecial Features: Kaiser Permanente is the nation’s largestnonprofit health plan serving more than 8.4 million members in9 states. The inland Empire Service Area consists of 2 medicalcenters and 18 satellite medical offices for 710,000 membersin the San Bernardino and Riverside counties of southernCalifornia.Contact Information:Patricia Gray, Clinical Operations ManagerKaiser Permanente Inland Empire Service Area9310 Sierra Ave.Fontana, CA 92335(909) 427-3838(909) 427-3830 (fax)[email protected]



nn kAiser PerMAnente MediCAl CAre ProgrAM—Metro los AngelesManaged Care PharmacyAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 10Starting Date: July 1Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Applicants must be a grad-uate of accredited college of pharmacy and licensed or eligiblefor licensure in California. Good communication skills required.Resident will develop a project with targeted care outcomes andpresent at Annual Western States Conference.Fringe Benefits: Paid insurance (medical, dental, vision), holi-days, vacation/sick daysSpecial Features: The Kaiser Permanente (KP) Los AngelesMedical Center is the tertiary care center for Kaiser Permanentein Southern California and provides comprehensive inpatient,outpatient, and ambulatory care services to Kaiser Permanentemembers. This residency program provides development andtraining for recently graduated pharmacists, with an emphasison pharmaceutical care and leadership to a diverse community.This program will allow the residents to become familiar withmanaged care pharmacy practice in an integrated health careprogram.Contact Information:Christine Fukunaga, PharmD, Residency Program CoordinatorKaiser Permanente Medical Care Program-Metro Los AngelesPharmacy Operations1515 N. Vermont Ave. #237Los Angeles, CA 90027(323) 857-4454(323) [email protected]://www.kaiserpharmacyresidency.org/

nn kAiser PerMAnente MediCAl Center ProgrAM —nortH sACrAMento vAlley AreAManaged Care Pharmacy PracticeAccredited: ASHP/AMCPLength of Program: 12 monthsNumber of Positions: 2Affiliation: Kaiser PermanenteApplication Deadline: January 14Starting Date: July 1Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Must be a graduate froman accredited school or college of pharmacy; PharmD preferred.

Must meet all qualifications of licensure in the state of Califor-nia. Must meet Kaiser Permanente’s employee requirements. Perthe rules for the Resident Matching Program, “this residency siteagrees that no person at this site will solicit, accept or use anyranking-related information from any residency applicant.”Fringe Benefits: 7 paid holidays, medical/vision/dental, vaca-tion/sick leaveSpecial Features: This program provides a unique learningopportunity for managed care pharmacy practice residenttraining. Our integrated health delivery system provides andcoordinates the entire scope of inpatient and outpatient care forour members. The core experiences include direct patient care,business administration and management, population-basedpharmaceutical care and drug information. Residents participateon the P&T Committee and are an integral part of the manage-ment team. Professional and career development is encouragedthroughout the residency.Contact Information:Bonnie Matsuoka, Ambulatory Care SupervisorKaiser Permanente Medical Center3240 Arden WaySacramento, CA 95825(916) 486-5124(916) 486-5386 (fax)[email protected]://kaiserpharmacyresidency.org

nn kAiser PerMAnente MediCAl CAre ProgrAM—tri-CentrAl serviCe AreAManaged Care organizationAccredited: ASHPLength of Program: 1 yearNumber of Positions: 2Affiliation: NoneApplication Deadline: January 14Starting Date: July 1Estimated Stipend: $43,7000Onsite Interview: YesEducational/Special Requirements: The applicant must be agraduate of an accredited school or college of pharmacy andeligible for licensure in the State of California. The applicantmust submit: an application for consideration, current CV,3 letters of recommendation, official school or college ofpharmacy transcript, copy of pharmacy intern license, letterof intent, and sample of recent school work (presentation orjournal article).Fringe Benefits: 2 weeks paid vacation, 6 paid holidays, sickleave, health benefits including dental/optical (also depen-dents), uniforms, office space, and reimbursement for off-siteexperiencesSpecial Features: The program provides the resident with anopportunity to participate in the provision of health care in a



large managed care environment. Resident will gain experiencein various practice areas: acute care, ambulatory care, physi-cian drug education, drug information, outpatient pharmacyand practice management. Ambulatory care practice includesanticoagulation, heart failure, integrated CVD, oncology, painmanagement, etc. Resident completing our program will have astrong foundation for future pharmacy practice.Contact Information:John Sie, Pharmacy Practice Residency Coordinator,Ambulatory Care Clinical Pharmacy Services SupervisorKaiser Permanente Medical Care Program Tri-Central Service Area,Pharmacy Operations1011 Baldwin Park Blvd.Baldwin Park, CA 90706(626) 851-5602(626) 851-5813 (fax)[email protected]://www.kaiserpharmacyresidency.org

nn kAiser PerMAnente MediCAl CAre ProgrAM—West los AngelesPharmacy PracticeAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Applicants must be agraduate of an accredited college of pharmacy and licensed oreligible for licensure in California; good communication skillsrequired; resident will develop a project with targeted careoutcomes and present at Annual Western States ConferenceFringe Benefits: Medical, dental, optical insurance, holidays,vacation/sick leaveSpecial Features: Hospital and ambulatory care experiences inthe nation’s largest integrated care organization, preventative anddisease state management in an integrated managed care setting.Flexible program molded to the resident’s interests.Contact Information:Michael Cinnamond, PharmD, Inpatient Pharmacy Directorto Residency Program DirectorKaiser Permanente Medical Care Program at West Los Angeles6041 Cadillac Ave., B 310Los Angeles, CA 90034(323) 857-2044(323) 857-2870 (fax)[email protected]://kaiserpharmacyresidency.org

nn kAiser PerMAnente MediCAl CAre ProgrAM,CAliforniAPharmacy Practice and drug information PracticeAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 26Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $43,700Onsite Interview: YesEducational/Special Requirements: Applicants must be a grad-uate of accredited college of pharmacy and licensed or eligiblefor licensure in California. Good communication skills required.Resident will develop a project with targeted care outcomes andpresent at Annual Western States ConferenceFringe Benefits: Medical, dental, optical insurance, holidays,vacation/sick leaveSpecial Features: Hospital and ambulatory care experiencesin the nation’s largest health maintenance organization, preven-tative and disease state management in an integrated managedcare settingContact Information:Elaine Watanabe, Pharmacy Services Manager-RecruitmentKaiser Permanente Pharmacy Operations Services,California Division9521 Dalen St.Downey, CA 90242(714) 796-4809(714) 796-4826 (fax)[email protected]://kaiserpharmacyresidency.org

nn kAiser PerMAnente nortHWest-—PortlAnd, oregonPharmacy Practice With emphasis in Managed CareAccredited: NoLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 15Starting Date: June 24Estimated Stipend: $41,000Onsite Interview: NoEducational/Special Requirements: PharmD preferred, eligiblefor Oregon and Washington licensureFringe Benefits: Health benefits, travel support to ASHP MCMand Western States Residency ConferenceSpecial Features: Multidisciplinary collaborative drug therapymanagement including cardiovascular risk factor management,hypertension, diabetes, anticoagulation, depression, pain, andasthma; drug information; drug use management; formulary



application; academic detailing; P&T committee support;research and teaching opportunities. Other opportunitiesinclude inpatient pharmacy, home infusion pharmacy, long-termcare pharmacy, and outpatient pharmacies located in ourmedical offices.Contact Information:Nancy Lee, Director of Clinical Pharmacy ServicesKaiser Permanente Northwest5717 NE 138th Ave.Portland, OR 97230(503) 261-7570(503) 261-7537 (fax)[email protected]

nn kAiser PerMAnente of georgiAManaged Care Pharmacy PracticeAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 10Starting Date: July 1Estimated Stipend: $39,500Onsite Interview: YesEducational/Special Requirements: PharmD preferred, eligi-bility for Georgia licensureFringe Benefits: Medical/dental/vision, holidays, vacation/sickleaveSpecial Features: Ambulatory care, acute care, drug informa-tion, and administrationContact Information:Diane Erdman, PharmD, BCPS, CDE, Residency Program DirectorKaiser Permanente750 Townpark LaneKennesaw, GA 30144(770) 514-5451(770) 514-5493 (fax)[email protected]

nn kelsey-seyBold CliniC/university of HoustonPharmacy Practice With an emphasis on Managed CareAccredited: ASHP/AMCPLength of Program: 1 yearNumber of Positions: 3Affiliation: University of HoustonApplication Deadline: January 7Starting Date: July 1Estimated Stipend: 34,000Onsite Interview: YesEducational/Special Requirements: PharmD or equivalent ex-perienceFringe Benefits: State of Texas benefits, 10 days of vacation,

support to attend AMCP, ASHP, TSHP, and either Alcalde orMid-West Residency ConferenceSpecial Features: Ambulatory care focused administrativeand clinical responsibilities and collaborations with other UHresidentsContact Information:Denise Martinez, Pharmacy Administrator of Clinical ServicesKelsey-Seybold ClinicPharmacy Administration8900 Lakes at 610 Dr.Houston, TX 77054(713) 442-6248(713) 442-5253 (fax)[email protected]://www.uh.edu/pharmacy/residencymenu.html

nn MArsHfield CliniCnonprofit Multispecialty ClinicAccredited: Precandidate statusLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 12Starting Date: July 1Estimated Stipend: $40,000-$45,000Onsite Interview: NoEducational/Special Requirements: Graduate of an accreditedschool of pharmacy, curriculum vitae, application form, officialcollege transcripts, 3 letters of recommendation, eligibility forWisconsin licensureFringe Benefits: See salary/benefits section of Marshfield ClinicPGY-1 Web siteSpecial Features: Marshfield Clinic is a private, not-for-prof-it, multispecialty group practice dedicated to serving patientsthrough accessible, high quality health care, research andeducation. Founded in 1916, Marshfield Clinic has become oneof the largest fully integrated health care systems in the UnitedStates. Marshfield Clinic serves more than 6,000 patients aday at 41 locations throughout northern, central and westernWisconsin. The Clinic has more than 700 physicians practic-ing in more than 80 specialties and subspecialties, and employssome 5,500 support personnel. The Marshfield Clinic pharmacysystem consists of a Clinical Pharmacy Services unit, outpatientdispensing pharmacies, a 340(b) pharmacy, sterile product phar-macies and an investigational drug program. A research projectis a requirement of the residency program and unique researchopportunities exist at Marshfield Clinic in collaboration withnationally recognized thought leaders in pharmacogenomics andclinical informatics.Available rotations thatmayalsooffer researchopportunities include community pharmacy, dermatology,drug information, internal medicine, managed care, outpatientcardiology, outpatient oncology/hematology, pediatric oncology/



hematology, pharmacy management, quality improvement/caremanagement, supply chain management, and the communityhealth care/indigent drug program.Contact Information:Sara Griesbach, Pharmacy Residency Program DirectorMarshfield Clinic1000 North Oak Ave.Marshfield, WI 54449(800) 541-2895(715) 387-5163 (fax)[email protected]://www2.marshfieldclinic.org/education/residency/residency_fellow/pharmacy/overview.asp

nn MAxor CorreCtionAl PHArMACyManaged Care PharmacyAccredited: YesLength of Program: 1 yearNumber of Positions: 1Affiliation: Various universitiesApplication Deadline: January 14Starting Date: July 1Estimated Stipend: $40,000Onsite Interview: YesEducational/Special Requirements: Graduate of accreditedschool of pharmacy; MUST obtain license before residencybeginsFringe Benefits: Matching 401K (up to 2.5%). Full medical,dental, and vision benefits. We provide training material andguidance for board certification in pharmacotherapy specialty.Special Features: During your residency, you will be assignedto a client whom you will assist in providing the most cost-effective care.Contact Information:Alexander Tunnell, Residency DirectorSecure Pharmacy Plus416 Mary Lindsay Polk Dr., Ste. 515Franklin, TN 37067(440) 808-8719(615) 771-4580 (fax)[email protected]

nn MedCo HeAltH solutions, inC.Managed Care PharmacyAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 11Starting Date: July 7Estimated Stipend: $40,000Onsite Interview: Yes

Educational/Special Requirements: BS or PharmD degree, eli-gibility for New Jersey licensure, managed care rotation or expe-rience preferred, 3 letters of recommendation, curriculum vitae,letter of intent, transcript, and onsite interviewFringe Benefits: Paid vacation, holidays, sick and personaltime; medical, dental, and life insurance; paid travel/registra-tion to professional meetings; leadership development training/education; paid New Jersey pharmacist licensureSpecial Features: Medco’s residency is an organized post-gradu-ate year-one (PGY1) managed care pharmacy practice trainingprogram that focuses on the development of the knowledge andskills pharmacists need in order to assume leadership roleswithin a managed care practice setting. Residents will also havedirect patient contact throughout the residency with responsibil-ity in Medicare Part D Medication Therapy Managementprogram. In addition to defined clinical, coverage management,and elective rotations, residents attend and present at a nationalP&T meeting, are exposed to legislative and regulatory aspectsof pharmacy, as well as innovative pharmacy models, automa-tion and information technology. The results of the resident’sresearch will be presented at a professional pharmacy confer-ence. The resident will prepare a final manuscript suitable forsubmission for publication.Contact Information:Doris Fishman, Executive DirectorClinical Therapeutics & Coverage Appeals ManagementMedco Health Solutions, Inc.100 Parsons Pond Dr., Mail Stop F2-3Franklin Lakes, NJ 07417(201) 269-6270(201) 269-1035 (fax)[email protected]

nn novArtis PHArMACeutiCAls CorPorAtionHealth economics & outcomes research fellowshipAccredited: NoLength of Program: 2 yearsNumber of Positions: 3Affiliation: Duke University; Scott & White

Health Plan/University of Texas at Austin;Rutgers University

Application Deadline: December 31Starting Date: July 1Estimated Stipend: $42,000-$52,000Onsite Interview: YesEducational/Special Requirements: Advanced degree inhealth services research, public health, health policy, pharmacy,economics, medicine, or other related areas, with someexperience in outcomes researchFringe Benefits: Medical insurance, vacationSpecial Features: The fellows will gain familiarity with outcomesresearch principles/application and experience in designing



research studies that examine economic, clinical and human-istic outcomes. The first year is spent at an academic/managedcare institution and the second year with Novartis’ HealthEconomics & Outcomes Research Department (Rutgers: bothyears at Novartis).Contact Information:Craig Plauschinat, PharmD, MPH, Assistant DirectorHealth Economics & Outcomes ResearchEvidence Based MedicineNovartis Pharmaceuticals CorporationOne Health PlazaEast Hanover, NJ 07936-1080(862) 778-2431(973) 781-3018 (fax)[email protected]

nn oPtiMA HeAltH PlAn/sentArA HeAltHCAreManaged Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: February 15Starting Date: July 1Estimated Stipend: $37,440Onsite Interview: YesEducational/Special Requirements: PharmD from an ac-credited school of pharmacy or equivalent experience, on-siteinterview, and eligible for Virginia licensureFringe Benefits: 2 weeks of paid vacation and uninterruptedstipend during minor illness included. A health insurance planis provided. Travel assistance is provided for continuing educa-tion events and other professional activities.Special Features: Resident will have exposure to an inte-grated healthcare system and system-wide Pharmacy Services,including a Drug Information Center. The resident will have theopportunity to precept students from Virginia CommonwealthUniversity and Hampton University Schools of Pharmacy andwork with medical residents from the Eastern Virginia MedicalSchool.Contact Information:Elizabeth Brusig, PharmD, Clinical PharmacistOptima Health Plan4417 Corporation LaneVirginia Beach, VA 23464(757) 552-7519(757) 687-6231 (fax)[email protected]://www.sentara.com/pharmacy/residency.html

nn ortHo-MCneil JAnssen sCientifiC AffAirs, llCdrug informationAccredited: NoLength of Program: 12 monthsNumber of Positions: 2Affiliation: Rutgers UniversityApplication Deadline: December 31Starting Date: July 1Estimated Stipend: CompetitiveOnsite Interview: YesEducational/Special Requirements: NoneFringe Benefits: NoneSpecial Features: NoneContact Information:Will Zachok, Associate Director, Medical CommunicationsOrtho-McNeil Janssen Scientific Affairs, LLC1000 Rte. 202 SRaritan, NJ 08869(908) 218-6283(908) 722-6402 (fax)[email protected]

nn ortHo-Mcneil JAnssen sCientifiC AffAirs, llCPharmaceutical industry, department of outcomes researchAccredited: NoLength of Program: 24 monthsNumber of Positions: 1Affiliation: Thomas Jefferson UniversityApplication Deadline: December 31Starting Date: June 2008 (flexible)Estimated Stipend: CompetitiveOnsite Interview: YesEducational/Special Requirements: NoneFringe Benefits: NoneSpecial Features: Fellows spend first year of program work-ing on outcomes research projects in an academic setting andsecond year in the pharmaceutical industry. Fellows have theopportunity to take coursework in biostatistics, epidemiology,economics, and other outcomes-related subjects.Contact Information:Michael Durkin, Director, Outcomes ResearchOrtho-McNeil Janssen Scientific Affairs, LLC1125 Trenton-Harbourton Rd.Titusville, NJ 08560(609) [email protected]



nn PerforMrx

Managed Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 15Starting Date: June 30Estimated Stipend: $37,000Onsite Interview: YesEducational/Special Requirements: PharmD degree from anACPE-accredited college of pharmacy, Pennsylvania pharmacistlicense or eligibility for licensure, completed application, letterof intent, curriculum vitae, 3 letters of recommendation, officialcollege transcripts, on-site interview (by invitation)Fringe Benefits: Benefits package including medical, dental,and vision insurance; 2 weeks paid vacation, 5 personal days,and paid holidays; funding available for attendance to profes-sional meetings; and tuition reimbursement availableSpecial Features: PerformRx is a Pharmacy Benefit Manage-ment company dedicated to providing quality, cost-effective careto members of Medicaid and Medicare programs. Throughmanaging this type of patient population, the resident isprovided an ideal environment to develop expertise in thefollowing areas: prior authorization, drug utilization review,health outcomes and disease management, formulary manage-ment, injectable drug management, pharmacy networkmanagement, new business implementation, and pharmacy callcenter services.Contact Information:Michelle Mason, Clinical Pharmacist, Formulary DepartmentPerformRx200 Stevens Dr.Philadelphia, PA 19113(215) 863-5123(215) 937-8722 (fax)[email protected]

nn PHArMACArePharmacy Benefits ManagementAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of Pittsburgh School of

PharmacyApplication Deadline: January 4Starting Date: July 1Estimated Stipend: $32,000Onsite Interview: YesEducational/Special Requirements: PharmD degree from anACPE-accredited school or college of pharmacy, minimum GPAof 3.0 on a 4.0 scale, currently licensed or eligible for pharmacy

licensure in the state of PennsylvaniaFringe Benefits: Comprehensive benefits package, no week-ends or holidays, financial support for professional managedcare meetings, no staffing requirements in a pharmacySpecial Features: The University of Pittsburgh School ofPharmacy and PharmaCare, one of the nation’s largest pharmacychain-based prescription management firms, offers an opportu-nity to practice in a dynamic pharmacy benefits managementenvironment and gain a clinical and administrative perspec-tive in the management of pharmacy benefit plans for a widevariety of clients. Multifaceted experience will include: DURcriteria development, clinical intervention activities, P&T activi-ties, clinical systems development, clinical account management,new business development, and proposals. Additionally, as apotential faculty member at the University of Pittsburgh Schoolof Pharmacy, the resident will participate in undergraduate andgraduate student instruction, as well as in the development ofeducational programs for the PharmaCare professional staff.Contact Information:Julie Legal, Supervisor of Clinical OperationsPharmaCare620 Epsilon Dr.Pittsburgh, PA 15238(412) 967-2300, ext. 75492(412) 968-2704 (fax)[email protected]

nn PHArMACeutiCAl CAre netWorkManaged Care Pharmacy PracticeAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $37,500Onsite Interview: YesEducational/Special Requirements: Graduate of accreditedcollege of pharmacy and licensed, or eligible for licensure, inCaliforniaFringe Benefits: Paid vacation and sick leave, health/dental/vision benefits, and educational support to attend professionalmeetingsSpecial Features: This residency will provide training informulary management, provider drug therapy education, drugbenefit design, outcomes analysis, and prior authorization.The resident will participate in drug utilization review, P&Tcommittee presentations, and interface with pharmacists from avariety of professional fields. The resident will learn to use PCN’sMedIntelligence software to identify drug therapy problems andmake appropriate interventions. This program includes rotationsin direct patient care, drug information and an opportunity to



rotate through the California Pharmacists Association.Contact Information:Philip Parsatoon, Vice President, Professional ServicesPharmaceutical Care Network9343 Tech Center Dr., Ste. 200Sacramento, CA 95826-2563(916) 361-4450(916) 414-4650 (fax)[email protected]

nn PresCriPtion solutionsManaged Care PharmacyAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 4Starting Date: July 1Estimated Stipend: $46,000Onsite Interview: YesEducational/Special Requirements: PharmD, CalifornialicensureFringe Benefits: 2 weeks paid vacation and paid holidays,professional leave to attend conferences, reimbursement forexpenses from professional meetingsSpecial Features: Clinical program development, formularymanagement, health outcomes research, client management,legal and regulatory affairs, industry relations, and specialtypharmacy. Residents will gain valuable experience in managedcare by rotating through clinical program development, clini-cal formulary management, clinical/Part D analytics, clinicalquality/compliance, client management, legal and regulatoryaffairs, industry relations, and specialty pharmacy. Residentswill attend the ASHP Midyear Clinical Meeting, CSHP Seminar,AMCP Educational Conference, AMCP Annual Meeting, andWestern States Conference.Contact Information:Heidi Lew, Director, Clinical ProgramsPrescription Solutions2300 Main St., Mail Stop CA134-0404Irvine, CA 92614(949) 252-4305(949) 474-4237 (fax)[email protected]://www.rxsolutions.com/b/residency/

nn regenCerx

Managed Care Pharmacy systemsAccredited: SeekingLength of Program: 12 monthsNumber of Positions: 2Affiliation: Regence BlueCross BlueShieldApplication Deadline: January 20Starting Date: July 1Estimated Stipend: $40,000Onsite Interview: YesEducational/Special Requirements: Potential residents mustpossess a BS degree in pharmacy or a PharmD degree from anACPE-accredited college of pharmacy, be licensed or eligible forlicensure in Oregon, and have strong motivation to pursue adynamic career in managed care pharmacy. Completion of apharmacy practice residency or equivalent experience is desired,but not required for consideration. An interview is required.Fringe Benefits: Health, dental, eye care, life and disabilityinsurance available; vacation time allotted; professional traveland stipend available; no weekends or holidays; no staffingrequirements in a pharmacy; commute expense reimbursementis available for public transportation; membership available to24 hour on-site fitness center.Special Features: RegenceRx is an internal pharmacy benefitprogram for The Regence Group. The Regence Group: Is thelargest affiliation of health care plans in the Pacific North-west/Mountain region, collectively includes 6 health plansserving nearly 3 million people in 4 states (Asuris NorthwestHealth Regence [Washington-based], BlueShield of IdahoRegence, BlueCross BlueShield of Oregon Regence, BlueCrossBlueShield of Utah Regence, BlueShield (Washington) RegenceLife and Health (Oregon-based). This residency will be primar-ily based in Portland, OR, headquarters for The Regence Group.RegenceRx is a not-for-profit program, offering a full array ofpharmacy benefit management (PBM) services. Science-basedevidence and effective utilization management are thefoundation for RegenceRx. RegenceRx focuses on: identifyingand promoting medications that provide the most value, ensuringquality and patient safety, and providing tools and informationto consumers and physicians. The RegenceRx clinical review/formulary process was adopted by the Academy of Managed CarePharmacy and is now known as the AMCP FormularySubmission Process.Contact Information:Sean Karbowicz, PharmDRegenceRxPO Box 1071, M/S 2PPortland, OR 97207-1071(503) 225-5367(888) 437-1510 (fax)[email protected]



nn roCHedrug informationAccredited: NoLength of Program: 12 monthsNumber of Positions: 2Affiliation: NoneApplication Deadline: January 1Starting Date: July 7Estimated Stipend: $44,000.00Onsite Interview: Upon invitationEducational/Special Requirements: NoneFringe Benefits: NoneSpecial Features: The purpose of the Roche Drug InformationSpecialty Residency is to prepare those interested in thepharmaceutical industry with grounding in industry-based druginformation practice. Residents receive intensive, experientialtraining in drug information practice including: working in acontact center, developing medical response databases, usingsophisticated informatics technology, implementing servicequality metrics, leading change, etc. Longitudinal experienceincludes working with drug safty, marketing, pharmacoeconom-ics/outcomes research, regulatory affairs and others. In addition,a 5-week rotation in an academic drug information centerprovides the resident with the requisite skills to conduct druguse evaluations, prepare formulary packages for the P&Tcommittees, etc.Contact Information:Mona Gandhi, Residency Program DirectorRoche340 Kingsland St.Nutley, NJ 07110(973) 562-5549(973) 562-2866 (fax)[email protected]

nnrutgers university/Horizon Blue Cross BluesHield of neW JerseyManaged Care organizationAccredited: NoLength of Program: 12 monthsNumber of Positions: 2Affiliation: Ernest Mario School of Pharmacy/

Horizon Blue Cross Blue ShieldApplication Deadline: January 15Starting Date: July 1Estimated Stipend: $30,000-$35,000Onsite Interview: YesEducational/Special Requirements: PharmD, eligiblility forNew Jersey state licensureFringe Benefits: Full medical coverage, dental and retirementbenefits, paid holidays, vacation and sick leaveSpecial Features: No weekend or staffing requirements; teach-

ing and preceptoring, mandatory; graduate courses offered atRutgers University; industry and PBM perspectives of managedcare. Residents will be trained to be an integral part of theformulary management, P&T process, evaluation of drug litera-ture and utilization review, medical and pharmacy policiesdevelopment, support disease state management programs,medication therapy management for Medicare part D members,benefit design, new technologies and research projects. Theywill play an active role in the pharmacy department at HorizonBlue Cross Blue Shield of New Jersey. Residents will also get agood industry and PBM perspective of managed care throughroutine business meetings and collaborative projects. Otherrequired activities include teaching and precepting at Rutgerspharmacy school and presentation of research at Spring AMCPnational meeting. No weekend or staffing requirements, travelexpenses to AMCP national meeting provided.Contact Information:Saira A. Jan, Associate Professor, Rutgers UniversityAssociate Director, Pharmacy Management at Horizon BCBSNJRutgers University/Horizon Blue Cross Blue Shield of NJ3 Penn Plaza East, PP-13QNewark, NJ 07105(973) 466-4575(973) 466-6266 (fax)[email protected]://www.horizonblue.com

nn rutgers, eMsoPPharmaceutical industry fellowshipAccredited: N/ALength of Program: 12-24 monthsNumber of Positions: 70Affiliation: Ernest Mario School of PharmacyApplication Deadline: February 1Starting Date: July 1Estimated Stipend: Not ListedOnsite Interview: YesEducational/Special Requirements: PharmDFringe Benefits: Not listedSpecial Features: Not listedContact Information:James Alexander, DirectorRutgers, EMSOP160 Frelinghuysen Rd., RM 405Piscataway, NJ 08854(732) [email protected]



nn sCott & WHite HeAltH PlAnManaged Care (nonprofit)Accredited: NoLength of Program: 1 yearNumber of Positions: 1Affiliation: College of Pharmacy, The University

of Texas at AustinApplication Deadline: February 1 (early January preferred)Starting Date: July 1Estimated Stipend: $35,116-$41,504, depending on priorpractice experience or previous residencyOnsite Interview: YesEducational/Special Requirements: PharmD, eligibility forTexas state licensureFringe Benefits: Fully paid medical, dental coverage; expensescovered for attendance at 2 national and one regional meeting(s),2 weeks paid vacationSpecial Features: Teaching, preceptoring, research; retrospec-tive pharmacy claims database analysis; industry and PBMmanaged care perspectives; marketing and sales exposure;participation in formulary and drug policy decision processes ata 200,000-member nonprofit, staff-model HMOContact Information:Paul Godley, PharmD, or Barry Browne, PharmDPharmacy Managed Care Residency Program DirectorsScott & White Health PlanPharmacy Administration OfficesScott & White Health Plan, 4236 Lowes Dr.Temple, TX 76502(254) 298-6143 (Dr. Godley) or (254) 724-5287 (Dr. Browne)(254) 724-1731 (fax)[email protected]; [email protected]

nn seleCtHeAltH (A serviCe ofinterMountAin HeAltHCAre)Managed Care Pharmacy PracticeAccredited: AMCP/ASHPLength of Program: 1 yearNumber of Positions: 1Affiliation: NoneApplication Deadline: January 10Starting Date: June 25Estimated Stipend: $44,000Onsite Interview: RequiredEducational/Special Requirements: Candidates must graduatefrom an ACPE-accredited pharmacy program with a doctor ofpharmacy degree with a minimum GPA of 3.0 on a 4.0 scale.Candidate must obtain Utah pharmacist licensure within thefirst 60 days of the program.Fringe Benefits: Health, dental, and life insurance; staffdiscounts; 10 days of vacation leave and 10 holidaysSpecial Features: Travel benefits to either the ASHP Midyear

Clinical Meeting or the AMCP Educational Meeting and theWestern States ConferenceContact Information:Jeffrey Dunn, Formulary and Contract ManagerSelectHealth (formerly known as IHC Health Plans)4646 West Lake Park Blvd., Ste. N3Salt Lake City, UT 84120(801) 442-7984(801) 442-3006 (fax)[email protected]://www.selecthealth.org

nn soutHern ArizonA vA HeAltH CAre systeMPharmacy Practice (Pgy1)Accredited: ASHP Accredited since 1982Length of Program: 12 monthsNumber of Positions: 8Affiliation: University of Arizona, Midwestern

University-Glendale, University ofSouthern Nevada, CreightonUniversity, Western University

Application Deadline: January 16Starting Date: July 1Estimated Stipend: $38,257 plus benefitsOnsite Interview: Interview required, onsite preferredEducational/Special Requirements: Curriculum vitae, 3 lettersof recommendation, college transcripts, 1 sample of writing,U.S. citizenshipFringe Benefits: Residents accumulate 13 days of paid vacationtime during the residency year. Sick leave is accrued at the rateof 4 hours every 2 weeks. Educational leave is provided toattend the Arizona Pharmacy Alliance Annual Meeting, theASHP Midyear Clinical Meeting, and the Western States Confer-ence for Pharmacy Residents, Fellows, and Preceptors. Travelfunds are available to offset some of the expenses for theseeducational meetings. Residents have access to the same medicaland plans that are offered to full-time employees of the Veterans’Administration (VA). These include a wide range of HMO andpreferred provider organization (PPO) health plans. Tucson alsohas a wide range of outdoor activities and excellent weather yearround.Special Features: This comprehensive residency includes abalance of inpatient and outpatient clinical pharmacyexperiences. Residents work in the areas of internal medicine,cardiology, neurology clinics, primary care, geriatrics, hospice,surgery/nutritional support, mental health, practice manage-ment, drug use evaluation (DUE), Pharmacy and TherapeuticsCommittee activities, drug literature evaluation, drug policydevelopment, teaching, research, and enhancing communica-tion abilities. Two months of elective experience are available.Contact Information:Christie Barreuther, RPh



Southern Arizona VeteransAdministration Health Care System3601 South Sixth Ave.Pharmacy Service 5-119Tucson, AZ 85723(520) 792-1450 ext 5388(520) 629-4700 (fax)[email protected]://www.southwest.va.gov/tucson/Pharmacy_Residency_Program1.asp

nn united drugsManaged Care PharmacyAccredited: NoLength of Program: 1 yearNumber of Positions: 1Affiliation: AMCPApplication Deadline: June 15Starting Date: September 1Estimated Stipend: $33,000Onsite Interview: YesEducational/Special Requirements: Graduate of an accreditedpharmacy school, PharmD preferred; ability to work indepen-dentlyFringe Benefits: Understanding of managed care from theperspective of a PBM, product development opportunities,ability to live in Arizona for a yearSpecial Features: Work hours negotiableContact Information:Jean Brown, Director of Clinical ServicesUnited Drugs7227 North 16th St., Ste. 160Phoenix, AZ 85020-5256(602) 678-1179, ext. 229(602) 678-0772 (fax)[email protected]

nn united HeAltH PHArMACeutiCAl solutionsManaged Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: N/AApplication Deadline: January 10 or until filledStarting Date: July 1Estimated Stipend: $48,000*Onsite Interview: Strongly preferredEducational/Special Requirements: PharmD and eligibility forpharmacy licensure in Minnesota required, experience in a com-munity pharmacy setting a plusFringe Benefits: 15 days paid time off (includes sick andvacation leave), paid holidays, reimbursement to attend AMCP

educational conference or annual meeting, on-site fitnesscenter;*stipend is adjusted as resident is responsible forprocurement of own health insuranceSpecial Features: Gaining experience with the second largestcommercial insurer in the nation, this residency is an idealopportunity for future master of business administration study.Residency will focus on pharmacy analytics and strategicplanning as related to prescription product tiering. Resident willwork with a leading analytic team to develop and present analy-ses that measure patterns of medication use and outcomes usingclaims data; assist with evaluation of pharmacoeconomic andclinical data; mentor pharmacy students; support integration ofacquisitions/mergers; and overall drive fact-based and datadriven decisions.Contact Information:Lida Etemad, Director, PDL Developmenti35901 Lincoln Dr.MN012-S234Edina, MN 55436(952) 992-5882(952) 992-7266 (fax)[email protected]

nn university At BuffAloAmbulatory CareAccredited: PendingLength of Program: 1 yearNumber of Positions: 2Affiliation: University at BuffaloApplication Deadline: October 1Starting Date: January 1Estimated Stipend: Not listedOnsite Interview: RequiredEducational/Special Requirements: PharmD or equivalentexperience requiredFringe Benefits: Health, dental, vision benefits; paid vacation;conference travel fundsSpecial Features: Unique experience designed to further refineskills in pharmaceutical care, in addition to developing skillsin program development and personnel and resource manage-ment. Resident is involved in coordination of clinical activitiesin a high-volume lobby-based pharmacy and a health-clinic-based ambulatory care pharmacy. The resident will participate inmedication histories, adherence counseling, and educationprograms. Development and implementation of disease man-agement initiatives, patient education, medical informatics andsupervision of PharmD students also significant aspects. Thisresidency will allow ample latitude for resident to exploreinterests and further develop skills as a practitioner. The residentwill also be appointed as a clinical instructor at University of



Buffalo, School of Pharmacy and Pharmaceutical Sciences.Contact Information:Ed Bednarczyk, PharmDUniversity at BuffaloSchool of Pharmacy and Pharmaceutical Sciences311 Hochstetter HallBuffalo, NY 14260(716) 645-2828(716) 645-2886 (fax)[email protected]

nn university of illinois At CHiCAgo& WAlgreens HeAltH initiAtivesfellowship-outcomes researchAccredited: NoLength of Program: 2 yearsNumber of Positions: 1Affiliation: University of Illinois & Walgreens

Health InitiativesApplication Deadline: February 1Starting Date: July 1Estimated Stipend: $36,000Onsite Interview: YesEducational/Special Requirements: Applicants should have aPharmD or MD (or equivalent) and have completed a pharmacypractice or managed care residency.Fringe Benefits: YesSpecial Features: This is a 2-year fellowship jointly offered byWalgreens Health Initiatives and the Center for Pharmacoeco-nomic Research at the University of Illinois at Chicago. The aimof the program is to train clinical pharmacists to conductresearch in drug therapy outcomes and pharmacoeconomics inthe managed care setting. Knowledge and experience will begained in the use of research tools to evaluate economic, human-istic, and clinical outcomes of drug therapy. Presentation andpublication of research findings in peer-reviewed venues isexpected. The fellowship is designed to facilitate career opportu-nities in managed care, health provider organizations,consulting, academia, or pharmaceutical industry.Contact Information:Glen Schumock, PharmD, MBAUniversity of Illinois at ChicagoCenter for Pharmacoeconomic Research833 S. Wood St. (MC 886)Chicago, IL 60612(312) 996-7961(312) 996-2754 (fax)[email protected]://www.uic.edu/pharmacy/research/cpr/

nn university of MArylAnd sCHool ofPHArMACy/CArefirst BlueCross BluesHieldManaged Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: CareFirst BlueCross BlueShield of

MarylandApplication Deadline: January 4Starting Date: July 1 (flexible)Estimated Stipend: $38,000Onsite Interview: YesEducational/Special Requirements: Graduate degree inpharmacyFringe Benefits: Health insurance, parking, support for nationalmeeting attendance, and poster presentationSpecial Features: Appointment as a clinical instructor at theUniversity of Maryland School of Pharmacy, Ambulatory CareClinics at HMO. Office with computer/references at managedcare organization. University of Maryland is an AA/EEO/ADAEmployer. Minorities and women are encouraged to apply.Contact Information:Catherine Cooke, Clinical Assistant ProfessorUniversity of Maryland School of Pharmacy5106 Bonnie Branch Rd.Ellicott City, MD 21043(410) [email protected]://www.pharmacy.umaryland.edu/pps/resident

nn university of texAs MediCAl BrAnCHCorreCtionAl MAnAged CArePgy1 Pharmacy residency Program With an emphasisin Managed CareAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of Texas Medical Branch

(UTMB)Application Deadline: February 15Starting Date: July 1Estimated Stipend: $35,000Onsite Interview: YesEducational/Special Requirements: Pharmacy degree fromaccredited college of pharmacy, Texas licensure or eligibilityfor Texas licensureFringe Benefits: UTMB is an AA/EO employer; closed majorholidays and weekends; generous vacation, holiday, and sickleave; competitive benefitsSpecial Features: Program strengths include automatedtechnology, telemedicine technology, ambulatory care, andmanaged care.



Contact Information:Stephanie Zepeda, Assistant Director of PharmacyUTMB Correctional Managed Care2400 Ave. IHuntsville, TX 77340(936) 437-5363(936) 437-5311 (fax)[email protected]://www.utmb.edu/cmc

nn university of PittsBurgH MediCAl Center (uPMC)HeAltH PlAnManaged Care PharmacyAccredited: NoLength of Program: 12 monthsNumber of Positions: 1Affiliation: UPMC Health System, University of

Pittsburgh School of PharmacyApplication Deadline: January 7Starting Date: July 1Estimated Stipend: $32,000Onsite Interview: PreferredEducational/Special Requirements: Applicants must havecompleted a PharmD degree and be eligible for PA licensure. Apharmacy practice residency is recommended but not requiredfor consideration. Please include letter of intent, curriculumvitae, college transcript, list of references (3) with contact infor-mation and 3 letters of recommendation submitted separately.Fringe Benefits: Health, dental, eye care, life, and disabilityinsurance available; vacation time allotted; professional traveland stipend available; no weekends or holidays; no staffingrequirements in a pharmacySpecial Features: UPMC Health Plan is owned by UPMC, whichis one of the nation’s top-ranked health systems. The HealthPlan covers commercial, Medical Assistance and Medicarepopulations. UPMC Health Plan has integrated resources fromCommunity Care Behavioral Health, University of PittsburghSchool of Pharmacy, as well as UPMC Health System. UPMCHealth Plan provides access to the complete health managementof the plan members (i.e., inpatient admissions, out-patientlaboratory values, diagnosis, etc.). Residency experience willinclude: DUR criteria development and review, clinical interven-tion activities, P&T monograph development and presentation,formulary management, policy development, medication therapymanagement protocol development and review, research projectfor publication, and the development of educational programsfor the Health Plan staff. Residents will have the opportunity todo an off-site PBM rotation. Additionally, through the Universityof Pittsburgh School of Pharmacy, the resident will participate instudent instruction.Contact Information:Jessica Daw, Clinical Pharmacy Specialist

UPMC Health Plan2 Chatham Center, 17th Floor112 Washington Pl.Pittsburgh, PA 15219(412) 454-7822(412) 454-5295 (fax)[email protected]

nn vA PAlo Alto HeAltH CAre systeMPgy2 Managed Care Pharmacy systemsAccredited: NewLength of Program: 12 monthsNumber of Positions: 1Affiliation: Stanford University School of

Medicine; University of Pacific ThomasJ. Long School of Pharmacy andHealth Sciences

Application Deadline: January 15Starting Date: July 1Estimated Stipend: $43,751Onsite Interview: YesEducational/Special Requirements: PharmD degree from anaccredited school of pharmacy, completion of a pharmacypractice residency or equivalent experience, U.S. citizenship,valid pharmacy license, Microsoft Access or advanced computerskills desirableFringe Benefits: Vacation (13 days per year), all federal holi-days, health/dental benefits, free parking, paid educationalleave for conferences, and private office with personal computersystem, no on-call responsibilitiesSpecial Features: State-of-the-art data warehouse; exposureto local, regional, and national pharmacy benefits managementactivities; university appointment; opportunity to do off-sitePBM rotationContact Information:Noelle Hasson, Pharmacy Benefits ManagerVA Palo Alto Health Care System3801 Miranda Ave. (119)Palo Alto, CA 94304(650) 493-5000, ext. 63601(650) 852-3444 (fax)[email protected]

nn vA sAn diego HeAltHCAre systeMManaged Care Pharmacy systemsAccredited: ASHP/AMCPLength of Program: 12 monthsNumber of Positions: 1Affiliation: University of the Pacific School

of PharmacyApplication Deadline: January 15Starting Date: July 1



Estimated Stipend: $46,500Onsite Interview: YesEducational/Special Requirements: PharmD plus first-yearresidency or equivalent experience, U.S. citizenship, personalstatement, curriculum vitae, transcripts, and 3 letters of recom-mendationFringe Benefits: 12-13 vacation and sick leave days, 11federal holidays, health and life insurance, free parking, paidleave, tuition and travel to required events, office with up-to-datecomputer systemsSpecial Features: This second year residency will providethe skills necessary for the practical application of Pharmaco-economic principles to formulary management and outcomesresearch in integrated healthcare systems. Education will includeformal pharmacoeconomics training classes and hands on appli-cation of principles. Work activities will encompass the VASDHS,Veterans Integrated Service Network 22 (VISN 22) PharmacyBenefits Management (i.e., Southern California Regional VA), andVA National Formulary tasks. Out-of-state and in-state travel isrequired. A university affiliated, teaching, integrated healthcaresystem with 100% computerized medical records, cutting edgepatient safety, pharmacy-managed clinics, pharmacist specialtypractices, and a dedicated pharmacy health outcomes divisionwith 4 full-time pharmacoeconomists. The pharmacy servicehas outstanding leadership with a long positive track record forinnovation and excellence at the local, state and national leveland a well-trained, well-published staff, most with residencies.This is an exciting opportunity to learn and start your career.Contact Information:Melissa Christopher, PharmD, DirectorPharmacoeconomics & Formulary ManagementVA San Diego Healthcare SystemPharmacy Service (119)3350 La Jolla Village Dr.San Diego, CA 92161(858) 552-8585, ext. 2783(858) [email protected]://www.san-diego.med.va.gov

nn vA sierrA PACifiC netWork (visn 21)Managed Care Pharmacy systemsAccredited: YesLength of Program: 12 monthsNumber of Positions: 1Affiliation: NoneApplication Deadline: February 1Starting Date: July 1Estimated Stipend: $43,500Onsite Interview: YesEducational/Special Requirements: PharmD degree preferred,pharmacy licensure in any state, U.S. citizenship required,

academic transcript, letter of intent, 3 letters of recommenda-tion, curriculum vitaeFringe Benefits: Health/dental benefits, 13 days of vacation,13 days of sick leave, 10 holidays, paid tuition and travel toapproved events, office with up-to-date computer systems,and paid administrative leave for conferences and educationaleventsSpecial Features: This progressive program is designed to teachknowledge, skills and abilities necessary to provide populationbased care using an extensive data warehouse, formularymanagement techniques, metrics and performance measures,pharmacoeconomics and health outcomes in 6 integrated VAhealth care systems with over 200,000 patients. Collaborationwith pharmacoeconomic pharmacists, database managers, andclinical program coordinators from these sites providesevidence-based care to our veteran population. The VA SierraPacific Network (VISN 21) includes 6 VA Medical Centers inNorthern California, Northern Nevada and Hawaii. Each facilityoffers primary, secondary and tertiary care from multipleCommunity Based Outpatients Clinics and complex and largeinpatient hospitals. All facilities are affiliated with academicprograms and universities in their geographic areas. The PBM islocated in Reno, NV, with opportunities to work throughoutVISN 21 and with the Data Warehouse Managers, PharmacyClinicians, physician staff and facility administrators. This is amulti-site program coordinating and managing quality andeconomic pharmacy programs for 6 large medical centersproviding care to over 200,000 veterans in a large geographicarea. Components of the program are coordinated throughvirtual learning, communication and computer techniques. Theresident will also be encouraged to have a longitudinal clinicalpractice site.Contact Information:Jannet Carmichael, PharmD, BCPS, FCCP, Pharmacy DirectorVA Sierra Pacific Network (VISN 21)Pharmacy Benefits Management Group1000 Locust St. (10N21R)Reno, NV 58502(775) 328-1279(775) 328-1400 (fax)[email protected]

nn veterAns AffAirs MediCAl Center, CinCinnAtiPgy1 Pharmacy systemAccredited: ASHPLength of Program: 12 monthsNumber of Positions: 3Affiliation: NoneApplication Deadline: January 10Starting Date: July 1Estimated Stipend: $39,807 plus benefitsOnsite Interview: Yes



Educational/Special Requirements: PharmD or equivalentexperienceFringe Benefits: Vacation, paid holidays, sick days, andadministrative time off for selected meetingsSpecial Features: ASHP-accredited pharmacy practice resi-dency providing experience in both acute care and outpatientprimary care while allowing for a variety of elective experiencesas well. The pharmacy resident will work under a collaborativepractice agreement with a medical team to facilitate achieve-ment of therapeutic goals through evidence-based disease statemanagement. The resident will have learning experiences incritical care, internal medicine, practice management, drugpolicy development, education and teaching. Upon comple-tion of this residency program, the pharmacy resident will haveachieved advanced practice skills that will enable the graduateto feel confident to function effectively in multiple healthcareenvironments and roles. The resident will also receive ateaching certificate from the University of Cincinnati College ofPharmacy.Contact Information:Jo-Ann Caudill, Residency Program DirectorDept. of Veterans Affairs Medical Center3200 Vine St.Pharmacy 119Cincinnati, OH 45220(513) 475-6322(513) 475-6981 (fax)[email protected]://vhacinweb1/iwtemp/Internship/Pharmacy Resident.htm

nn WAlgreens HeAltH initiAtivesPharmacy Benefits Management firmAccredited: AMCP/ASHPLength of Program: 12 monthsNumber of Positions: 3Affiliation: NoneApplication Deadline: January 15Starting Date: July 1 (flexible)Estimated Stipend: $37,000Onsite Interview: YesEducational/Special Requirements: PharmDFringe Benefits: Medical plan, 2-week vacation, holidays, travelexpense budgetSpecial Features: This managed care pharmacy residencyprogram is designed to allow residents to work within thevarious departments of a pharmacy benefits management firmincluding, but not limited to, care management, drug use policy,PBM operations, clinical sales, and specialty pharmacy. Theresidents will gain practical experience and will develop skillsrelated to disease management, health outcomes, medicationmanagement strategies, formulary management, drug utilizationreview, drug information, and other clinical services. Addition-

ally, residents will have the opportunity to gain exposure tothe pharmaceutical industry, be involved in professional organi-zations, and precept pharmacy students.Contact Information:Judith Sommers-Hanson, Manager Clinical Educationand Shared FacultyWalgreens Health Initiatives1415 Lake Cook Rd., MS# L444Deerfield, IL 60015(847) 964-8331(847) 374-2669 (fax)[email protected]

nn WellPoint nextrx

Managed Care PharmacyAccredited: ASHP/AMCPLength of Program: 12 monthsNumber of Positions: 1Affiliation: Blue Cross of California, PrecisionRx,

University of Southern CaliforniaApplication Deadline: January 11Starting Date: July 1Estimated Stipend: $46,000Onsite Interview: YesEducational/Special Requirements: PharmD from an ACPE-accredited college of pharmacy or equivalent experience, eligiblefor California licensure, good academic standing, excellentwritten and verbal communication skillsFringe Benefits: Health insurance, 2 weeks paid vacation, paidholiday and sick days, attendance at the Western StatesConference, at a national pharmacy organization meeting and ata WellPoint NextRx National P&T meetingSpecial Features: The program is designed to provide theresident with an overall managed care experience. The residentrotates through several areas within the PBM, including druginformation, therapy management, senior and state sponsoredbusiness, prior authorization centers, mail order pharmacy,clinical analytic strategies, and pharmaceutical contracting andindustry relations. The program also includes rotations at BlueCross of California health plan and University of SouthernCalifornia direct patient care sites.Contact Information:Vanessa MacGregor, Clinical Pharmacy ResidentWellPoint NextRx8407 Fallbrook Ave., MS CAAF01-0007West Hills, CA 91304(818) 313-5082(818) 313-5110 (fax)[email protected]



nn xCendAHealth outcomes research fellowshipAccredited: NoLength of Program: 2 yearsNumber of Positions: 1Affiliation: University of South Florida, College

of Public HealthApplication Deadline: January 4Starting Date: July 1Estimated Stipend: Not listedOnsite Interview: YesEducational/Special Requirements: PharmD or equivalent(residency preferred)Fringe Benefits: Competitive salary, health insurance, vacation,401(k), tuition for required classes, and travel expenses to1 national meeting per yearSpecial Features: This 2-year, degree-granting fellowship pro-vides a unique research and education experience in anoutcomes consulting environment. Research activities include,but are not limited to, quality improvement programs, databaseanalysis, economic modeling, and development of research-based manuscripts. In addition, the Fellow will obtain a MSPHor MPH degree from the University of South Florida, College ofPublic Health.Contact Information:James H. Jackson, IV, PharmD, MPH, DirectorXcenda4114 Woodlands Pkwy, Ste. 500Palm Harbor, FL 34685(727) 771-4100(727) 771-4145 (fax)[email protected]://www.xcenda.com

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