OSU program promotes drug safety and cost control
By Lee Sherman
From the 12th floor of a tower on Portland's bustling riverfront, Oregon State University pharmacists are quietly at work saving Oregonians millions of dollars.
Professors Dean Haxby and Dan Hartung are cutting costs for taxpayers while improving health for patients through OSU's Drug Use Research and Management group. Part oversight, part outreach, part research, the program was created 15 years ago to dig into prescription data for the Oregon Health Plan, the state's Medicaid program. Overseen by the Department of Human Services (DHS) and a 12-member board of Oregon doctors and pharmacists, its mission is threefold: to root out waste, advise health-care providers and safeguard patients.
"The program helps Medicaid stretch its resources while promoting safe, effective use of medications," Haxby explains.
Getting the Word Out
From their offices, which overlook the aerial tram linking Oregon Health & Sciences University's waterfront and West Hills facilities, Haxby and Hartung coordinate with the program's Salem office, directed by OSU pharmacist Kathy Ketchum, to find and investigate trends or patterns that can signal unwarranted costs or unacceptable risks. Issues as diverse as Tylenol overuse, antidepressant dosages and smoking cessation come to their attention as they pore over quarterly "chart reports" showing all meds prescribed to Medicaid patients. They get the word out via a Web site (they had 36,000 "hits" in September) and a listserv with nearly 700 subscribers.
Their findings not only help patients and prescribers, they also guide drug-use policy statewide. "We do all sorts of drug policy analysis for DHS and the Legislature," notes Ketchum.
Examples of activities and impacts include:
Tylenol Alert. Too much acetaminophen, the active ingredient in Tylenol, can cause liver damage. Problems can arise when patients take over-the-counter cough and cold meds without their doctor's knowledge on top of prescriptions that also contain acetaminophen (such as the painkiller Vicodin). A review of state Medicaid pharmacy claims showed high cumulative levels of acetaminophen among some patients. OSU intervened, sending letters to both patients and doctors to alert them to the danger.
Dose Consolidation. Taking an antidepressant in two small doses per day costs more than taking it all in one larger dose. But the cost of drugs isn't always on the doctor's radar. To raise physician awareness, the OSU pharmacists sent an alert in the form of a "prescription change form," asking doctors to consider changes in dosing. The state can save as much as $1,000 per patient per year simply by consolidating doses, Hartung found in a recent study.
Academic Detailing. When pharmaceutical reps tout their products' benefits to physicians, they call it "product detailing." Basically, it's a sales pitch. The information, therefore, can be unreliable and incomplete. To give doctors a full, balanced picture, OSU convenes small groups of physicians for "academic detailing" - drug information that is based not on sales goals but on the best available scientific evidence and long-term outcome data. A new pilot project to develop an academic-detailing curriculum for four family-practice clinics in the rural communities of Reedsport, Wheeler and Klamath Falls is under way.
Use Only as Directed
Foster Care Expose. After a 2007 Oregonian article exposed potentially unsafe prescribing of psychotropic drugs in the foster care system, the Legislature passed House Bill 3114 requiring an annual review of the drug profiles of children in the system. OSU is assisting DHS in these reviews. To help inform lawmakers, the group analyzed prescription drug use among foster children compared to use among other Medicaid children. Other OSU-developed tools include a literature review and a set of criteria for identifying inappropriate prescribing.
Off-Label Drug Marketing. A scan of drug usage in the late 1990s turned up unusually high rates of a drug called Neurontin (gabapentin), an anticonvulsant. OSU launched a study and discovered that 95 percent of prescriptions were for conditions not FDA-approved in the label. The off-label use was costing the state millions of dollars and was exposing patients to unknown risks for purported, but unproven, benefits. "We were some of the first to publish on that," Haxby says. After a $400 million settlement with the drug company several years later, the state attorney general granted funds to create education modules (web, video and live) informing prescribers about evidence-based drug evaluation and pharmaceutical industry marketing.
Tobacco Cessation. A soon-to-be-launched referral program will help smokers quit the habit. When an Oregon Health Plan patient fills a nicotine-replacement or other cessation prescription, OSU identifies the patient as a candidate for additional free support services. The new program will reach out to those would-be quitters by hooking them up with the state's Quit Line, which provides four counseling sessions by phone. "Drugs by themselves aren't that effective in helping people stop smoking," says Ketchum. "Studies show that counseling makes those drug therapies much more likely to work."
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