Gershovich Olga E, Billups Sarah J, Delate Thomas, Hoffman Caroline Kicklighter, Carroll Nikki
Kaiser Permanente Colorado, 8383 W. Alameda Ave., Lakewood, CO 80226, USA.
J Manag Care Pharm. 2006 Apr;12(3):246-53. doi: 10.18553/jmcp.2006.12.3.246.
Managed care organizations can increase the value of drug therapy by negotiating discounts on drug acquisition costs with pharmaceutical manufacturers and promoting use of preferred drugs, including the conversion of patients to preferred medications. This investigation was designed to assess conversion success, migraine drug utilizations, and patient satisfaction with a clinical pharmacist-managed conversion program from sumatriptan to rizatriptan ODT, both formulary drugs.
This was a retrospective cohort study conducted in a managed care organization for patients aged 18 years or older who had picked up at least one outpatient prescription for any sumatriptan dosage form at the pharmacy between January 2002 and June 2002. Patients. pharmacy and medical data were reviewed to assess eligibility (e.g., no history of rizatriptan failure) for conversion from sumatriptan to rizatriptan orally disintegrating tablet (ODT). There was no copayment difference for members for rizatriptan ODT versus sumatriptan. A questionnaire was developed to assess 2 domains: (1) patient satisfaction with the medication conversion process and (2) preference for rizatriptan ODT or sumatriptan. A random sample of 315 patients who initiated conversion to rizatriptan ODT was surveyed. Electronic pharmacy claims were reviewed to determine the number of patients who were successfully converted from sumatriptan to rizatriptan ODT. Pharmacy expenditures and total health care utilization and expenditures in the 180 days prior to (baseline) and after the conversion (followup) to rizatriptan ODT were compared for the cohorts of subjects who were successfully converted and those patients who were not successfully converted.
Therapeutic conversion from sumatriptan to rizatriptan ODT was attempted in 457 patients; 214 (47%) were successfully converted. The only difference between the 2 cohorts at baseline for the 6 months prior to attempted conversion was a higher mean number of sumatriptan doses per patient per month (PPPM) in the 243 failed conversions (mean 3.5, SD 2.9) compared with the 214 successful conversions (mean 2.8, SD 2.8, P =0.003). The median triptan doses increased by 1.0 PPPM in both cohorts (P =0.882), from 2.0 to 3.0 doses PPPM in the group of successful conversions and from 2.7 to 4.0 in the group of unsuccessful conversions. The survey response rate was 55% for both successful and for unsuccessful conversions. More than 90% of the patients in both cohorts were satisfied with the level of care provided by the clinical pharmacy staff during medication conversion, and there was no difference between the 2 cohorts in patient satisfaction (P=0.761). Rizatriptan ODT was preferred by 68.0% and 8.5% of successful and failed conversion subjects, respectively (P <0.001). Using representative group purchase prices, triptan expenditures for successful conversion subjects were reduced by a median of -2 dollars (6 %) PPPM while triptan expenditures for unsuccessful conversions increased by a median of 8 dollars (P <0.001). There were no differences for either cohort in median PPPM changes in migraine-related office visits (0.0 median change in office visits, P =0.748) or office-visit costs (0 dollars median change, P =0.861) for preconversion versus postconversion attempts Regression modeling identified that lower total counts of sumatriptan doses filled during baseline period was an independent predictor of successful conversion to rizatriptan ODT (P <0.001). There was an average of 3.5 triptan medication fills per patient for successful conversion during the 6-month follow-up period, with 78% of these subjects filling at least 2 prescriptions for rizatriptan ODT during this period.
This conversion program for sumatriptan to rizatriptan ODT was successful in converting almost half of primary care patients to the preferred product despite the absence of a copayment incentive for members to agree to the conversion. There were no measurable medical or economic consequences of the conversion, and patient satisfaction with the quality of care was maintained. Future efforts are likely to have a higher success rate if focused on converting patients with less-severe migraine headaches, as measured by the need for baseline rescue medication, since lower acuity was the only independent predictor of successful conversion in this conversion program for 2 triptan drugs.
管理式医疗组织可以通过与制药商协商药品采购成本折扣以及推广使用优选药物（包括将患者转换为使用优选药物）来提高药物治疗的价值。本研究旨在评估从舒马曲坦转换为利扎曲普坦口腔崩解片（ODT，二者均为处方药物）这一临床药师管理的转换项目的转换成功率、偏头痛药物使用情况以及患者满意度。
这是一项在管理式医疗组织中开展的回顾性队列研究，研究对象为2002年1月至2002年6月期间在药房领取过至少一张任何剂型舒马曲坦门诊处方的18岁及以上患者。对患者、药房和医疗数据进行审查，以评估从舒马曲坦转换为利扎曲普坦口腔崩解片（ODT）的 eligibility（如无利扎曲普坦治疗失败史）。利扎曲普坦ODT与舒马曲坦对会员来说没有共付差异。设计了一份问卷来评估两个领域：（1）患者对药物转换过程的满意度；（2）对利扎曲普坦ODT或舒马曲坦的偏好。对315名开始转换为利扎曲普坦ODT的患者进行了随机抽样调查。审查电子药房报销记录，以确定从舒马曲坦成功转换为利扎曲普坦ODT的患者数量。比较了成功转换和未成功转换的受试者队列在转换为利扎曲普坦ODT之前（基线）和之后180天内的药房支出、总医疗保健利用率和支出。
457名患者尝试从舒马曲坦进行治疗性转换为利扎曲普坦ODT；214名（47%）成功转换。在尝试转换前6个月的基线期，两个队列之间唯一的差异是，在243例转换失败的患者中，每位患者每月（PPPM）使用舒马曲坦的平均剂量数较高（平均3.5，标准差2.9），而214例成功转换的患者中该数值为（平均2.8，标准差2.8，P =0.003）。两个队列中曲坦类药物的中位剂量均增加了1.0 PPPM（P =0.882），成功转换组从2.0剂量PPPM增加到3.0剂量PPPM，未成功转换组从2.7剂量增加到4.0剂量。成功转换和未成功转换患者的调查回复率均为55%。两个队列中超过90%的患者对临床药房工作人员在药物转换期间提供的护理水平感到满意，且两个队列在患者满意度方面没有差异（P=0.761）。成功转换和未成功转换的受试者中，分别有68.0%和8.5%的人更喜欢利扎曲普坦ODT（P <0.001）。使用代表性的团购价格，成功转换受试者的曲坦类药物支出中位数减少了-2美元（6%）PPPM，而未成功转换者的曲坦类药物支出中位数增加了（P <0.001）。对于两个队列，转换前与转换后尝试相比，偏头痛相关门诊就诊的PPPM中位数变化（门诊就诊中位数变化为0.0，P =0.748）或门诊就诊费用（中位数变化为0美元，P =0.861）均无差异。回归模型确定，基线期填充的舒马曲坦剂量总数较低是成功转换为利扎曲普坦ODT的独立预测因素（P <0.001）。在为期6个月的随访期内，成功转换的患者平均每人填充3.5次曲坦类药物，其中78%的受试者在此期间至少填充了2张利扎曲普坦ODT处方。
尽管没有共付激励措施促使会员同意转换，但从舒马曲坦到利扎曲普坦ODT的这一转换项目成功地将近一半的初级保健患者转换为使用优选产品。转换没有可衡量的医学或经济后果，且患者对护理质量的满意度得以维持。如果未来的努力集中在转换那些偏头痛头痛症状较轻的患者（以基线期需要急救药物来衡量），可能会有更高的成功率，因为在这两种曲坦类药物的转换项目中，较低的严重程度是成功转换的唯一独立预测因素。
