Fischer Michael A, Schneeweiss Sebastian, Avorn Jerry, Solomon Daniel H
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA.
N Engl J Med. 2004 Nov 18;351(21):2187-94. doi: 10.1056/NEJMsa042770.
Over the past five years, selective cyclooxygenase-2 inhibitors (coxibs) have accounted for a growing proportion of prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). To control these expenses, many state Medicaid programs have implemented prior-authorization requirements before coxibs can be prescribed. We evaluated the effect of such programs on the use of coxibs by Medicaid beneficiaries.
We surveyed state Medicaid agencies to determine whether prescription of coxibs required prior authorization and, if so, the criteria for authorization. For each program, we compared these criteria with evidence-based recommendations for prescribing of coxibs. Using data for all filled prescriptions in 50 state Medicaid programs from 1999 through the end of 2003, we calculated the proportion of defined daily doses of NSAIDs accounted for by coxibs. Time-series analyses were used to measure the changes in prescription patterns after the implementation of each prior-authorization program.
By 2001, coxibs accounted for half of all NSAID doses covered by Medicaid. This proportion varied widely according to the state in 2003, from a low of 11 percent to a high of 70 percent of all NSAID doses. Twenty-two states implemented prior-authorization programs for coxibs during the study period. Overall, the implementation of such programs reduced the proportion of NSAID doses made up by coxibs by 15.0 percent (95 percent confidence interval, 10.9 to 19.2 percent), corresponding to a decrease of 10.28 dollars (95 percent confidence interval, 7.56 dollars to 13.00 dollars) in spending per NSAID prescription. The effect of such programs was not influenced by the degree to which a prior-authorization program incorporated evidence-based prescribing recommendations.
The use of coxibs and spending on NSAIDs varies widely by state and declined substantially after the implementation of prior-authorization programs. Determining whether these reductions are clinically appropriate will have important implications for the development of rational drug-reimbursement policies.
在过去五年中，选择性环氧化酶-2抑制剂（coxibs）在非甾体抗炎药（NSAIDs）处方中所占比例日益增加。为控制这些费用，许多州医疗补助计划在开具coxibs处方前实施了预先授权要求。我们评估了此类计划对医疗补助受益人群使用coxibs的影响。
我们对各州医疗补助机构进行了调查，以确定coxibs处方是否需要预先授权，若需要，授权标准是什么。对于每个计划，我们将这些标准与基于证据的coxibs处方建议进行了比较。利用1999年至2003年底50个州医疗补助计划中所有已配药处方的数据，我们计算了coxibs占非甾体抗炎药规定日剂量的比例。采用时间序列分析来衡量每个预先授权计划实施后处方模式的变化。
到2001年，coxibs占医疗补助涵盖的所有非甾体抗炎药剂量的一半。2003年，这一比例因州而异，低至所有非甾体抗炎药剂量的11%，高至70%。在研究期间，22个州实施了coxibs预先授权计划。总体而言，此类计划的实施使coxibs占非甾体抗炎药剂量的比例降低了15.0%（95%置信区间为10.9%至19.2%），相当于每张非甾体抗炎药处方的费用减少了10.28美元（95%置信区间为7.56美元至13.00美元）。此类计划的效果不受预先授权计划纳入基于证据的处方建议程度的影响。
coxibs的使用和非甾体抗炎药的支出因州而异，在实施预先授权计划后大幅下降。确定这些减少是否在临床上合理对于制定合理的药物报销政策具有重要意义。
