Using Evidence-Based Medicine to Design State Drug Programs

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States that are interested in reducing the costs and maximizing the benefits of their pharmaceutical benefit programs have a new resource to turn to—the Drug Effectiveness Review Project. DERP is a collaboration of organizations, most of them public, that have joined together to obtain the best available evidence on the comparable effectiveness and safety of drugs in the same class and to apply this information to public policy and other related activities. By September 2006, the project plans to produce 25 final reports of drug class reviews, of which 12 were commissioned independently by three states, and update them every six months. The Commonwealth Fund recently funded a review of the project's effectiveness, which will take place simultaneously. It will combine qualitative and quantitative data to assess the strategies states are using to apply evidence-based medicine, the states' experiences with them, the effects these strategies are having on utilization, and the factors that affect the use of different strategies. States currently have the challenging task of managing the pharmaceutical budget for a diverse population that includes Medicaid beneficiaries, State Children's Health Insurance Program enrollees, state employees and retirees, and prisoners. This responsibility carries with it competing demands. Appropriate drug expenditures can help to contain costs for other services, as well as improve the health and overall quality of life for the population they serve. These costs, however, must be balanced with the states' severe and recurring budget problems and the upward spiral of pharmaceutical prices.

The intervention: States that are interested in reducing the costs and maximizing the benefits of their pharmaceutical benefit programs have a new resource to turn to—the Drug Effectiveness Review Project. DERP is a collaboration of organizations, most of them public, that have joined together to obtain the best available evidence on the comparable effectiveness and safety of drugs in the same class and to apply this information to public policy and other related activities. The project is being led by the Center for Evidence-Based Policy, which is housed in the Department of Public Health and Preventive Medicine at Oregon Health and Science University. By September 2006, the project plans to produce 25 final reports of drug class reviews, of which 12 were commissioned independently by three states, and update them every six months. The Commonwealth Fund recently funded a review of the project's effectiveness, which will take place simultaneously. It will combine qualitative and quantitative data to assess the strategies states are using to apply evidence-based medicine, the states' experiences with them, the effects these strategies are having on utilization, and the factors that affect the use of different strategies. States currently have the challenging task of managing the pharmaceutical budget for a diverse population that includes Medicaid beneficiaries, State Children's Health Insurance Program enrollees, state employees and retirees, and prisoners. This responsibility carries with it competing demands. Appropriate drug expenditures can help to contain costs for other services, as well as improve the health and overall quality of life for the population they serve. These costs, however, must be balanced with the states' severe and recurring budget problems and the upward spiral of pharmaceutical prices. As a result, many states have turned to evidence-based medicine in an effort to control their prescription drug costs and promote appropriate access. However, they have found this to be a significant challenge as most studies are not designed to be useful in policymaking. Instead, they tend to be limited in scope, highly technical, and focused on unrelated populations. Further, these studies often are sponsored by drug manufacturers that have an incentive to demonstrate their products are more effective than the competition. This problem is compounded by the fact that state policymakers typically lack the training necessary to develop relevant research questions and find answers that would help establish preferred drug lists and formularies or implement tiered copayments and joint purchasing efforts. Now states, including those that already have established preferred drug lists and hired pharmacy benefit managers, can turn to the Drug Effectiveness Review Project (DERP). DERP is a collaboration of organizations that have come together to obtain the best available evidence on effectiveness and safety comparisons between drugs in the same class and to apply this information to public policy and related activities. Essentially, it aims to serve as a "communication linchpin" between researchers and state policymakers. The project is governed and financed by its participating organizations, which also determine the drug classes to study. Through September 2006, these organizations have agreed to produce 13 final reports of drug class reviews and updates of these and an additional 12 final reports, which were commissioned by the states of Oregon, Washington, and Idaho and will be completed, every six months. These reviews include reports on the following drug classes: ACE inhibitors, angiotensin receptor blockers, second generation antidepressants, anti-epileptic drugs, second generation anti-histamines, atypical anti-psychotics, beta adrenergic blockers, calcium channel blockers, estrogens, inhaled corticosteroids, long-acting opioids, non-steroidal anti-inflammatory drugs, oral hypoglycemics, proton pump inhibitors, skeletal muscle relaxants, statins, triptans, and urinary incontinence drugs. The evidence that will be used for these reports and their regular updates is a series of comprehensive, up-to-date, and unbiased systematic reviews conducted by the Evidence Based Practice Center (EPC) with oversight and coordination from the Oregon EPC. DERP also is supported in its efforts by the Center for Evidence-Based Policy. These drug class reviews aim to estimate the comparative effectiveness and safety of health care treatments by systematically examining their similarities and differences across multiple research studies. The EPC, in consultation with the participating organizations, write the key research questions that define the scope of the investigation. Multiple databases are searched for articles, which are included only if they meet set quality standards. The data are abstracted and then synthesized to address the key questions, with the report undergoing a peer review process before it is finalized. Every six months, the key questions are reviewed based on recent developments and the assessment is completed once again. At the end of the project, states should have better data on which to base their decisions. The Commonwealth Fund recently funded an evaluation that is designed to assess both the success of individual state efforts to apply evidence-based medicine to managing the pharmacy benefit and DERP's collaborative effort. This evaluation also will draw lessons on the broader applicability of this approach to other states, private sector drug purchases, and the federal government's newly enacted Medicare drug benefit. Specifically, National Academy for State Health Policy and Georgetown University researchers will combine qualitative and quantitative data to answer three key questions about the use of evidence-based medicine to manage the pharmacy benefit. They are: 1. What strategies are states using to apply evidence-based medicine to manage pharmacy costs and promote appropriate access to prescription drugs, and what has been their experience in using these strategies? 2. How much shift occurs in the utilization of various drugs within a particular therapeutic class when strategies, such as preferred drug lists, are applied to that class of drugs? 3. How do various factors, including the source of evidence, degree of stakeholder input, and choice and strength of enforcement mechanisms, make a difference in the development, operation, effectiveness, or acceptance of the strategy? This review will help policymakers assess their choices for using research evidence to contain drug costs and promote appropriate access. It also will provide consumers, advocates, and providers with information about how these strategies affect them. For more information Web sites: www.ohsu.edu and www.ahrq.gov/clinic/epc/ohsuepc.htm Contacts: Mark Gibson, Deputy Director, Center for Evidence-based Policy E-mail mgibson@milbank.org. Mark Helfand, OHSU EPC Director E-mail helfand@ohsu.edu.

October 2004

Publication Details

Publication Date:
July 12, 2004

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