Cox Emily R, Kulkarni Amit, Henderson Rochelle
Office of Evidence-Based Pharmacy Benefit Design, Express Scripts, Inc., St. Louis, MO 63121, USA.
Ann Pharmacother. 2007 Dec;41(12):1946-53. doi: 10.1345/aph.1K253. Epub 2007 Oct 30.
Changing formulary status is a common strategy to encourage greater use of lower-cost brand and generic drugs.
To examine the relationship between patient and plan design factors and formulary adherence after the formulary status change of atorvastatin.
We conducted a cross-sectional, cohort study of patients enrolled in one of 2139 commercial (no Medicare or Medicaid) plans that offer a 3-tier benefit design and changed atorvastatin from formulary to nonformulary status on January 1, 2006. Adults on atorvastatin therapy who were receiving targeted communications in the fourth quarter of 2005 were included for analysis. We used bivariate and multivariate logistic regression analyses to examine the relationship between covariates and formulary adherence for patients receiving atorvastatin through retail or home delivery (HD) pharmacies.
A total of 211,083 patients met the study inclusion criteria, and more than 42% switched from atorvastatin to a formulary statin (33.1% retail, 51.8% HD). Patient-related factors that consistently and positively predicted switching across retail and HD channels included female sex, prior statin switching, and member outreach to the pharmacy benefit manager through telephone or Web use. Plan design factors that positively influenced switching to the preferred agent included step therapy, brand preferred/nonpreferred copayment differential, and among retail users, receipt of a rapid response education letter. Adoption of step therapy and the rapid-response program in retail settings increased the odds of switching by 1.3. Compared with patients who were paying a differential of $10 or less in retail channels, those who were paying $11-15, $16-20, and $21 and higher had increased odds of switching of 35% (95% CI 1.31 to 1.39), 41% (95% CI 1.37 to 1.46), and 80% (95% CI 1.74 to 1.86), respectively. In HD, compared with patients who were paying a differential of $15 or less, those who were paying $16-30, $31-40, and $41 and higher had increased odds of switching to a formulary preferred agent of 20% (95% CI 1.17 to 1.23), 23% (95% CI 1.19 to 1.26), and 59% (95% CI 1.55 to 1.64), respectively.
Through appropriate program and plan design, plan sponsors' impact on formulary adoption is maximized.
改变药品目录状态是鼓励更多使用低成本品牌药和仿制药的常见策略。
研究阿托伐他汀药品目录状态改变后患者及计划设计因素与药品目录依从性之间的关系。
我们对参加2139个商业（无医疗保险或医疗补助）计划之一的患者进行了一项横断面队列研究，这些计划提供三级福利设计，并于2006年1月1日将阿托伐他汀从药品目录状态变更为非药品目录状态。纳入分析的对象为在2005年第四季度接受针对性沟通的正在接受阿托伐他汀治疗的成年人。我们使用双变量和多变量逻辑回归分析来研究通过零售或送药上门（HD）药房接受阿托伐他汀治疗的患者的协变量与药品目录依从性之间的关系。
共有211,083名患者符合研究纳入标准，超过42%的患者从阿托伐他汀换用了药品目录中的他汀类药物（零售渠道为33.1%，送药上门渠道为51.8%）。在零售和送药上门渠道中始终能正向预测换药的患者相关因素包括女性、既往他汀类药物换药史以及会员通过电话或网络与药房福利管理人员联系。对换用首选药物有正向影响的计划设计因素包括阶梯治疗、品牌首选/非首选药物的自付费用差异，在零售用户中，还包括收到快速反应教育信。在零售环境中采用阶梯治疗和快速反应计划使换药几率增加了1.3倍。与在零售渠道自付费用差价为10美元或以下的患者相比，自付费用为11 - 15美元、16 - 20美元以及21美元及以上的患者换药几率分别增加了35%（95%置信区间1.31至1.39）, 41%（95%置信区间1.37至1.46）以及80%（95%置信区间1.74至1.86）。在送药上门渠道中，与自付费用差价为15美元或以下的患者相比，自付费用为16 - 30美元、31 - 40美元以及41美元及以上的患者换用药品目录中首选药物的几率分别增加了20%（95%置信区间1.17至1.23）, 23%（95%置信区间1.19至1.26）以及59%（95%置信区间1.55至1.64）。
通过适当的项目和计划设计，计划主办方对药品目录采用情况的影响得以最大化。
