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fmd175 Slide Prescribing Cascade and Pharmaco-Economics PDF
fmd175 Slide Prescribing Cascade and Pharmaco-Economics PDF
Pharmaco-economics
Dep. Farmakologi dan Terapeutik,
Fakultas Kedokteran
Percentage
Visiting Findings
Polypharmacy
Causes and Consequences
Contributing factors
Consequences
Age
Multiple medical conditions
Multiple symptoms
Copious prescribing
Multiple providers
Multiple pharmacies used
Self treating
Drug regimen changes
Prescribing cascade
Interactions
A+B
A+B
B+C
A+B
A+D
B+D
A+C
A+C
B+C
C+D
Number of
Interactions
0
1
3
Kaskade Peresepan
PRESCRIBING CASCADE
obat 1
Drug 1
obat 2
Drug 2
Nyeri
dengkul
terapi
Simtom baru
terapi ikutan
OAINS
Nyeri
ulu hati
antasida
konstipasi
laksansia
diare
dst
rematologis
serangan
GOUT
OAINS
PSMBA
gastroenterologis
hidro
klorotiazida
Hipertensi
misoprostol
diare . . . . .
IATROGENIK
(iatro = dokter)
Adverse
effect
Rise in blood
pressure
Thiazide
diuretics
Metoclopramide Parkinsonian
treatment
symptoms
Subsequent
treatment
Antihypertensive
treatment
Treatment with
levodopa
obat anti-gout
sebagai terapi
lanjutan setelah
pemberian tiazid
anti-Parkinson
sebagai terapi lanjutan
setelah pemberian
metoklopramide
2.5
2
1.5
1
0.5
0
none
low
medium
high
none
< 25 mg
25-50 mg
> 50 mg
none
< 10 mg
10-20 mg
3
2.5
2
1.5
1
0.5
0
6
5
4
3
2
1
0
> 20 mg
NYERI
OAINS
Retensi
cairan
diuretik
TD
meningkat
Anti-
hipertensi
GGN GI TRACT
Nyeri
ulu hati
misoprostol
antasida
Kaskade
Prescribing
Peresepan
Cascade
Lingkaran setan
Lansia
Bermacammacam
problem klinis
efek samping
PolyPolipharmacy
farmasi
tanda/
simptom baru ?
terapi
lanjutan
PAIN
CANCER
ALZHEIMER
DISEASE
NSAID=Rp
fluid
retention
increase
BP
PUB
heart
burn
Rp
Rp
Rp
Rp
Iatrogenic Cost
PharmacoEconomics
Adding drugs to the formulary involves careful
consideration of:
Efficacy
Safety
Quality
Cost
Cost factors are becoming more important
Science of pharmacoeconomics is emerging
Pharmacoeconomics
Cost (total resources consumed in producing a good or
service)
Price (the amount of money required to purchase an item)
available
Introduced
GI ulcer
Arthritis
H2-antagonist
NSAID
Mental
health
Womens
health
AIDS
TCA
PPI
COXIB,
anti-TNF agents
SSRIs, Atypical
Anti-Psychotics
biphosphonate
- (osteoporosis)
-
Protease
Inhibitors/cocktail
Medical Outcomes
ECHO Model
Economic
Expense
Savings
Cost
Avoidance
Clinical
Cure
Comfort
Survival
Humanistic
Physical
Emotional
Social
pharmacoeconomics
outcomes
research
pharmaceutical
care
Definition
Economic outcomes measure that focuses on
the evaluation of pharmaceutical products and
pharmaceutical services
Clinical
Economic
Humanistic
cost-minimisation
cost-benefit
Pharmacoeonomics
cost-utility
cost-effectiveness
Cost-Minimization Analysis
Compares the total relevant cost-difference
between treatment alternatives (products or
services) that are considered to produce
identical outcomes
Clinical
Economic
Humanistic
Cost-Minimization Analysis
Examples:
comparing an AB rated generic drug to its brand
name equivalent
comparing the cost of a multiple dose schedule to
a once daily schedule that is equally safe and
effective
analyzing the cost of administering and
monitoring the same drug in two different settings
Generically Equivalent
Pharmaceutically equivalent
Therapeutically equivalent
The same drug with the same effect,
but the product is from a different
manufacturer
AB rating in Orange Book
Cost-Effectiveness Analysis
Compares the total relevant cost of therapy to
the effectiveness when the outcomes for the
alternatives are NOT equal
Clinical
Clinical
Economic
Economic
Humanistic
Cost-Effectiveness
Cost-Effectiveness Analysis
Difference in costs
IV
The new treatment is
Less effective and more
expensive
I
The new treatment is
more effective and
more expensive
Difference in
effects
III
The new treatment is
less effective and
less expensive
II
The new treatment is
more effective and
less expensive
Drug
product
Percentage of nimesulide
dissolved
15 min
30 min
Aulin
89.25
98.45
Nimesulide
Dorom
52.43
63.85
Cost-Effectiveness Analysis
Less $
More $
Worse
outcome
Better
outcome
Clinical
Economic
Humanistic
Cost-Benefit Analysis
Evaluates the value of all resources consumed in
implementing a program or intervention
against the value of the outcome
Clinical
Economic
Humanistic
Cost-Benefit Analysis
Example:
_____________________________________________
Cost
Benefit Average B:C Ratio
New
Benefit/Cost
Service
$25,000
$45,000
1.8:1
_____________________________________________
Corticosteroids
Antianxiety/sedative agents
**Adjuvant analgesic agents**
Outcome Measures
Indicator
Clinical
Outcome
BP
Renal failure
Stroke
MI
Death
QOL
Cost/ mmHg BP
Cost/stroke avoided
Cost/life year saved
Hyperlipidemia
LDL levels
Angina
MI
Death
QOL
Cost/MI avoided
Cost/point in LDL
Diabetes
A1C
BG levels
Retinopathy
Nephropathy
Death
QOL
Cost/change in A1C
Cost/kidney transplant
avoided
Asthma
FEV,
peak flow
Exacerbation
event
Death
QOL
Cost/symptom free
day
Disease
Hypertension
Humanistic
Outcome
Economic Outcome
Outcome Measures
for pain management
Indicator
Clinical
Outcome
Humanistic
Outcome
Economic
Outcome
pain
CV event
GI event
Renal failure
QOL
Cost/ mmHg BP
Cost/stroke avoided
Cost/life year saved
NSAID
CELECOXIB
Less
CV event
QOL
Cost >>
IBUPROFEN
Better
GI event
QOL
Cost <<
Agent
Pharmacoeconomics
say NO
- -New
-
$$
say YES
Now what ?
+++
do it!
Medications
Effectiveness
MOST EXPENSIVE
THERAPY
THERAPEUTIC
FAILURE
first do no harm!
Medical License
My name is Bond,
James Bond OO7,
I have License to kill
Medical profession
has a better License,
to save and
also to kill
12000
12000
9000
8000
6000
4000
3000
0
Private pharmacy
Healthcenter
Private hospital
Drug store
Public hospital
Consumer Price Index
Developed countries
(7 - 20%)
Bulgaria
Czech Rep.
Hungary
Croatia
Poland
Estonia
Slovenia
Lithuania
Transitional countries
(15 - 30%)
Mali
Egypt
China
Indonesia
Thailand
Tunisia
Jordan
Argentina
South Africa
Developing countries
(24 - 66 %)
10
20
30
40
50
60
70
Cost-Effectiveness Analysis
Example:
_____________________________________________________
Total Cost/
Lives Saved/
Average CE
100 Patients
100 Patients
Ratio
Drug A
$220,000
79
Drug B
$20,000
78
$2784.81/ life
saved
$256.41/ life
saved
_____________________________________________________
Cost-Effectiveness Analysis
Incremental Cost Effectiveness Ratio (ICER)
ICER =
(cost of A cost of B)
(effectiveness of A effectiveness of B)
pharmacotherapeutics
Adverse effect
Therapeutic
effect
Minimal
Maximal
Maximal
Yes
Minimal
No
Critical evaluation
on selecting medicine
say NO
$$
ADRs
- -New
-
say YES
Now what ?
+++
do it!
Medications
Effectiveness
10
20
30
40
50
Number of studies
Published studies
Finished studies
Clinicians
Employers
Insurers
Generics
PBMS
Branded
Drug Cos
Govt
Govt
Patients
Methodology
Cost measurement
unit
Outcome unit
Cost minimization
Dollars
Cost benefit
Dollars
Dollars
Cost effectiveness
Dollars
Cost utility
Dollars
Perspective
pharmaco-economics
The point of view considered in economic
analyses influences the outcomes and costs
considered to be most relevant:
Provider
Patient
Payer
Society