Studies evaluating the cost-effectiveness of clinical pharmacy services (CPS) are needed to justify implementation and reimbursement. Through a systematic review, we describe services provided by pharmacists and their economic outcomes. We conducted a literature search of published studies in PubMed, Ovid, and Embase from January 2011 through December 2017. Manuscripts evaluating a CPS with patient-level economic outcomes and conducted in the United States were included. Study risks of bias were classified by study design characteristics. Economic evaluations were classified according to the presence of a comparator, and cost and outcome measures included. The quality of full economic evaluations was assessed using the Quality of Health Economic Studies (QHES) instrument. Descriptive statistics were used to summarize CPS characteristics. After screening, 115 studies wereincluded. Type of service provided included general pharmacotherapy (41%), disease management (30%), and targeted drug program (17%). Settings included hospital (34%), ambulatory care (28%), and community pharmacy (17%). Study designs were considered high risk of bias (use of a historical control group or no control group) in 69% of cases while 25% were medium risk of bias (non-randomized with a concurrent control group) and 6% were low risk of bias (randomized experimental or multigroup interrupted time series). Economic evaluation types were descriptive studies that measured cost and/or outcomes of a CPS (55%), comparative studies that measured cost or outcomes of a CPS and a comparator (37%), and full evaluations that measured cost and outcomes of a CPS and a comparator (8%). Among nine full evaluations, the median (range) QHES score was 74 (59-95) and four reported the CPS as being more effective at a lower cost. Few full economic evaluations were conducted, but supported the cost-effectiveness of CPS. Use of a comparator group and measurement of economic inputs and outcomes would strengthen the body of evidence. K E Y W O R D Scost-benefit analysis, health services research, pharmacoeconomics, pharmacy
PURPOSE: Treatment of chronic myelogenous leukemia (CML) with tyrosine kinase inhibitors (TKIs) has improved survival but is associated with significant financial burden. We measured the annual trend in TKI utilization, Medicare gross payment, and patient out-of-pocket (OOP) expenditure from 2007 to 2016. METHODS: We used SEER linked to Medicare part-D claims data to identify prevalent CML cases from 2007 to 2016. TKI utilization was measured as the proportion of cases with at least one TKI fill in each year. Average TKI gross payment and median per-member per-month OOP expenditure were calculated from claims data and plotted annually from 2007 to 2016. Year-to-year percent change in gross payment and OOP expenditure was compared with inflation indices. RESULTS: The cohort included 3,189 CML cases with at least one TKI claim. The proportion of prevalent patients with a TKI fill in a year increased from 17.9% in 2007 to 52.8% in 2015. The average annual gross payment per 30-day supply of a TKI increased by an average of 12.8% throughout the period from $9,000 to $10,000 US dollars in 2016. There was no increasing trend in median OOP expenditure per 30-day supply, which varied between $450 and $600 US dollars. CONCLUSION: Rising TKI use and TKI drug prices place considerable financial pressure on Medicare part-D insurers. Although there was no increasing trend in OOP expenditure, it may be burdensome for Medicare patients who are likely retired on a fixed income. Our findings support legislation that mitigates increasing drug prices to protect the Medicare system and its beneficiaries.
6582 Background: The strength of associations between pre-diagnosis self-reported health (SRH) and mortality differ by medical condition, with a moderately strong association reported among cancer patients. Less is known about the impact of SRH on survival among patients diagnosed with multiple myeloma (MM). We aimed to evaluate pre-diagnosis SRH in relation to survival in a cohort of older MM patients. Methods: We analyzed a prospective cohort from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database of patients 65 years and older diagnosed with first primary MM. Survey responses to a single general health question (asking patients to self-report their health as excellent, very good, good, fair, or poor) were used to determine pre-diagnosis SRH, grouped as high (excellent/very good/good) or low (fair/poor). We used multivariable Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for associations between SRH and risks of all-cause and cancer-specific mortality. Results: Of 521 MM patients with pre-diagnosis SRH data, the mean (SD) age at diagnosis was 76.8 (6.1) years with 60% of patients identifying as white, 18% as black, and 32% reporting low SRH. Compared to patients reporting high SRH, patients reporting low SRH were older, had lower education levels, more comorbidities, and lower Veterans-RAND 12 physical health and mental health component summary scores. In multivariable analyses, MM patients with low SRH had a 28% increased risk of all-cause mortality (HR = 1.28, 95% CI = 1.00, 1.64) and a non-statistically significant 19% increased risk of cancer-specific mortality (HR = 1.19, 95% CI = 0.87, 1.61) compared to MM patients reporting high SRH. Conclusions: Our findings suggest that lower SRH is highly prevalent among MM patients prior to diagnosis and is associated with modestly increased all-cause mortality. At a minimum, low SRH deserves clinical attention to determine how older MM patients’ quality of life may be compromised. The mechanism by which SRH affects mortality in MM should be further assessed and efforts should be made to identify whether any of the underlying mechanisms linking SRH and mortality in MM are mutable.
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