University of Oklahoma College of Pharmacy, CPB-222, P.O. Box 26901, Oklahoma City, OK 73126-0901.
J Manag Care Spec Pharm. 2014 Jun;20(6):612-21. doi: 10.18553/jmcp.2014.20.6.612.
Public policymakers often struggle with increased membership and limited budgets. Restrictions, commonly in the form of prior authorizations, are often placed on more costly pharmaceuticals, especially when lower cost or more effective products are available. Restrictions placed on products for difficult-to-manage disease states must be reviewed in order to ensure that unintended clinical consequences do not occur.
To assess the impact of a prior authorization policy for montelukast on clinical outcomes for asthma and allergic rhinitis among children and adolescent members of Oklahoma Medicaid (MOK) from 2007 through 2010.
Monthly individual-level utilization data were collected from MOK paid pharmacy and medical claims from January 1, 2007, through December 31, 2010, for members with asthma and/or allergic rhinitis. Members who were continuously eligible for the entire 48-month review period were included. The effect of a prior authorization policy for montelukast on emergency room (ER) utilization, disease-related physician office visits (DRV), and antibiotic prescription utilization (ABX) was analyzed using segmented logistic regression.
For all 3 outcomes, decreases in mean number of claims per member per month were detected when comparing the pre-implementation and post-implementation prior authorization periods for all 3 disease states of asthma, allergic rhinitis, or both. Odds of having an ER event at the point of prior authorization implementation were 0.71 (P less than 0.001) and were 1.29 (P less than 0.001) and 1.26 (P less than 0.001) for DRV and ABX, respectively. Overall trend in odds was 1.02 (P less than 0.001), 0.93 (P less than 0.001), and 0.95 (P less than 0.001) for ER, DRV, and ABX, but during the post-implementation period, the odds were 0.92 (P less than 0.001) for ER and 1.03 (P less than 0.001) for both DRV and ABX. The final result was an increasing trend prior to implementation for ER, a decrease at implementation, and a continued decrease in odds of an event in the post-implementation period. However, for DRV and ABX, there was an overall decrease in trend regardless of period, with a small increase in odds at the point of implementation.
While there was a point increase at implementation for DRV and ABX, the overall trend remained negative, indicating that no unexpected adverse clinical outcomes occurred. Additionally, no signal was found in ER use after implementation to indicate that unintended consequences occurred, particularly for those patients with asthma.
公共政策制定者经常面临成员增加和预算有限的问题。通常会对更昂贵的药物（尤其是在有成本更低或更有效的产品时）施加限制，这种限制通常以事先授权的形式出现。对于难以管理的疾病状态的产品施加的限制必须进行审查，以确保不会出现意外的临床后果。
评估俄克拉荷马州医疗补助计划（MOK）中 2007 年至 2010 年期间，对 montelukast 的事先授权政策对患有哮喘和/或过敏性鼻炎的儿童和青少年患者的临床结果的影响。
从 2007 年 1 月 1 日至 2010 年 12 月 31 日，从 MOK 支付的药房和医疗索赔中收集了哮喘和/或过敏性鼻炎患者的每月个人层面的利用数据。包括在整个 48 个月审查期间持续符合条件的成员。使用分段逻辑回归分析 montelukast 事先授权政策对急诊室（ER）利用率、与疾病相关的医生就诊次数（DRV）和抗生素处方利用率（ABX）的影响。
对于所有 3 种结果，在比较哮喘、过敏性鼻炎或两者同时发生的所有 3 种疾病状态的实施前和实施后的预先授权期间，每个成员每月的平均索赔数量均有下降。在实施事先授权时，发生 ER 事件的可能性为 0.71（P<0.001），而 DRV 和 ABX 分别为 1.29（P<0.001）和 1.26（P<0.001）。总体趋势的可能性为 1.02（P<0.001），0.93（P<0.001）和 0.95（P<0.001），分别用于 ER、DRV 和 ABX，但在实施后期间，ER 的可能性为 0.92（P<0.001），DRV 和 ABX 的可能性均为 1.03（P<0.001）。最终结果是实施前 ER 呈上升趋势，实施时下降，实施后事件的可能性持续下降。但是，对于 DRV 和 ABX，无论在哪个时期，趋势都呈总体下降趋势，实施时的可能性略有增加。
尽管 DRV 和 ABX 在实施时略有增加，但总体趋势仍然为负，表明没有发生意外的临床不良后果。此外，实施后 ER 的使用没有发现信号表明发生了意外的后果，特别是对于那些患有哮喘的患者。
