Conference: 2010 International PHA Conference and Scientific Sessions
Release Date: 06.24.2010
Presentation Type: Abstracts
Kyrychenko P, Fargotstein M, Johlie M, O’Rourke J, Frobel D, Moore M, Reid S, Andrews L.
CVS Caremark, Centreville, VA, USA
BACKGROUND: Pulmonary Arterial Hypertension (PAH) is a life-threatening and rare disorder that is responsible for approximately 200 deaths per year and has an annual prevalence rate of 5-15 per million. It is among the top 10 costliest conditions within the specialty pharmacy area and can cost upwards of $100,000 a year. With a number of therapeutic options available and benefit coverage being under both pharmacy and medical, comprehensive management of this patient population can be a challenge. Applying nationally recognized guidelines for medication utilization review can assist in understanding current prescribing habits of PAH drugs and assist in controlling the cost of therapy. The objective of this study was to assess rates and reasons of inappropriate prescriptions of PAH biologics identified by the PAH medication utilization management program.
METHODS: The analysis utilized a large de-identified administrative database of patients enrolled into the PAH medication utilization program on specialty pharmaceuticals. PAH specialty pharmaceuticals were identified by GPI-6: 401700/401600 or GPI-7: 4014306. Appropriateness of their prescription was assessed using ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension. A retrospective cohort design was applied. The pediatric patients and those patients that could not undergo cardiac catheterization due to their medical conditions were excluded.
RESULTS: In total, 493 adult patients (70% female) were prescribed PAH specialty pharmaceuticals and were evaluated for medical appropriateness in 2009. About 301 (61%) were 60 years of age and older. Of those studied, 43 (9%; 95% CI: 6%–12%) did not meet the ACCF/AHA 2009 criteria and were denied for the treatment. In all cases “diagnosis not PAH” or “PAH diagnosis not confirmed by right heart catheterization” were the reasons for denials.
CONCLUSIONS: There was a high rate (9%) of prescriptions presented for PAH medications that did not meet ACCF/AHA 2009 guidelines: the diagnosis was not PAH or the right heart catheterization was not performed to confirm PAH. Opportunities exist to increase adherence to guidelines which in turn may improve the rate of appropriate specialty pharmaceutical utilization.