Morgan Steve, Hanley Gillian, Greyson Devon
Open Med. 2009;3(3):e131-9. Epub 2009 Aug 4.
To synthesize methodologically comparable evidence from the published literature regarding the outcomes of tiered formularies and therapeutic reference pricing of prescription drugs.
We searched the following electronic databases: ABI/Inform, CINAHL, Clinical Evidence, Digital Dissertations & Theses, Evidence-Based Medicine Reviews (which incorporates ACP Journal Club, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessments and NHS Economic Evaluation Database), EconLit, EMBASE, International Pharmaceutical Abstracts, MEDLINE, PAIS International and PAIS Archive, and the Web of Science. We also searched the reference lists of relevant articles and several grey literature sources. We sought English-language studies published from 1986 to 2007 that examined the effects of either therapeutic reference pricing or tiered formularies, reported on outcomes relevant to patient care and cost-effectiveness, and employed quantitative study designs that included concurrent or historical comparison groups. We abstracted and assessed potentially appropriate articles using a modified version of the data abstraction form developed by the Cochrane Effective Practice and Organisation of Care Group.
From an initial list of 2964 citations, 12 citations (representing 11 studies) were deemed eligible for inclusion in our review: 3 studies (reported in 4 articles) of reference pricing and 8 studies of tiered formularies. The introduction of reference pricing was associated with reduced plan spending, switching to preferred medicines, reduced overall drug utilization and short-term increases in the use of physician services. Reference pricing was not associated with adverse health impacts. The introduction of tiered formularies was associated with reduced plan expenditures, greater patient costs and increased rates of non-compliance with prescribed drug therapy. From the data available, we were unable to examine the hypothesis that tiered formulary policies result in greater use of physician services and potentially worse health outcomes.
The available evidence does not clearly differentiate between reference pricing and tiered formularies in terms of policy outcomes. Reference pricing appears to have a slight evidentiary advantage, given that patients' health outcomes under tiered formularies have not been well studied and that tiered formularies are associated with increased rates of medicine discontinuation.
综合已发表文献中关于分层处方集和处方药治疗参考定价结果的方法学可比证据。
我们检索了以下电子数据库：ABI/Inform、CINAHL、临床证据、数字学位论文、循证医学综述（其中包括《美国内科医师学会杂志俱乐部》、Cochrane对照试验中心注册库、Cochrane系统评价数据库、Cochrane方法学注册库、疗效评价文摘数据库、卫生技术评估和英国国家医疗服务体系经济评价数据库）、EconLit、EMBASE、国际药学文摘、MEDLINE、PAIS国际和PAIS存档以及科学引文索引。我们还检索了相关文章的参考文献列表和几个灰色文献来源。我们查找了1986年至2007年发表的英文研究，这些研究考察了治疗参考定价或分层处方集的效果，报告了与患者护理和成本效益相关的结果，并采用了包括同期或历史对照组的定量研究设计。我们使用Cochrane有效实践与护理组织小组开发的数据提取表的修改版提取并评估了可能合适的文章。
从最初的2964条引用文献列表中，有12条引用文献（代表11项研究）被认为符合纳入我们综述的条件：3项参考定价研究（发表在4篇文章中）和8项分层处方集研究。参考定价制度的引入与计划支出减少、转向使用首选药物、总体药物使用量减少以及医生服务使用量短期增加有关。参考定价与不良健康影响无关。分层处方集的引入与计划支出减少、患者成本增加以及处方药治疗的不依从率上升有关。根据现有数据，我们无法检验分层处方集政策会导致更多地使用医生服务以及可能导致更差健康结果这一假设。
现有证据在政策结果方面并未明确区分参考定价和分层处方集。参考定价似乎具有轻微的证据优势，因为分层处方集下患者的健康结果尚未得到充分研究，而且分层处方集与停药率上升有关。
