Idaho DUR Committee Meeting Record

Transcription

1 Idah DUR Cmmittee Meeting Recrd Date: August 23, 2012 Time: 9:00 a.m. 3:00 p.m. Lcatin: Idah Medicaid, 3232 Elder Street, Bise, Idah, Cnference Rm D-W Mderatr: Cmmittee Members Present: Paul Cady, Pharm.D, Myrna Olsn-Fisher, NP Others Present:, Chris Jhnsn, Pharm.D., Jane Gennrich, Pharm.D.,, William Milne, RPh Cmmittee Members Absent: Mark Turner, MD, Erich Garland, MD, Perry Brwn, MD, Wayne Baures, RPh, Suzette Cper, Pharm.D., AGENDA ITEMS PRESENTER OUTCOME/ACTIONS Cmmittee Business Call t rder Review f Minutes frm April 19, 2012 Apprval will be requested frm the Bard by . Fllw-up Studies updates Citalpram High Dse On March 28, 2012 the FDA issued a revised Drug Safety Cmmunicatin with updated recmmendatins: The maximum recmmended dse f citalpram is 40 mg per day fr patients under 60 years and 20mg per day fr patients ver 60 years. Citalpram is recmmended t be discntinued in patients wh are fund t have persistent QTc measurements greater than 500ms. Magellan surveyed data frm 1/1/2012 t 3/31/2012 and there were 77 recipients ver 60 years receiving 40mg f citalpram daily. The fllw up review f the current prescribing trend fr recipients ver 60 years f age shws 10 new patients in June 2012 and 51 claims fr the same patients frm first quarter 2012 with a paid claim fr citalpram 40mg daily fr patients 60 years and lder. The bard recmmended that Idah Medicaid add an edit t deny claims at pint f sale fr citalpram dses greater than 20mg daily fr patients 60 years and lder. 1

2 Current Interventins/Outcmes studies Narctic Patterns f Use in Chrnic Nn-Malignant Pain Chris Jhnsn, Pharm.D. Backgrund: At the January 19, 2012 DUR Bard meeting the Idah P&T Cmmittee recmmendatins fr narctic analgesic DUR activities were discussed. The resulting DUR activity included generatin f prfiles fr the tp 150 recipients by ttal narctic claim cunt between May 1, 2011 thrugh December 31, 2011, fr the recipients wh had at least ne paid narctic claim in each f the 24 mnths fr the perid ending December The 150 prfiles were hand reviewed by Idah Medicaid pharmacists. Six f the recipients had cancer diagnses and were therefre excluded frm analysis. The fllwing data is frm the 144 prfiles f recipients wh were receiving narctics fr chrnic nn-malignant pain. Dr. Eide and Dr. Jhnsn reviewed the fllwing data. Average length f time fr cntinuus piid use = 8.2 years. Average number f different piids = 2.9 Average daily mrphine equivalents = 256 mg equivalents Average number f prescribers per participant = 2 Other cncurrent ptentially addictive drugs being used the majrity f patients were n cncurrent ptentially addictive drugs, mst cmmnly benzdiazepines and/r muscle relaxants and/r sedative hypntics. (see slide fr detail)* Diagnsis and indicatins mst patients had multiple diagnses with the mst cmmn diagnses being lumbag/back pain and chrnic pain syndrme. Average days prir t refill = 27 Number f Medicaid pharmacy lck-in patients included 4 patients currently enrlled in the lck-in prgram. Nn-Medicaid piid prescriptin fills using the Idah Bard f Pharmacy reprts 43 f the 144 patients (30%) had piid prescriptins paid fr utside f Medicaid pharmacy benefits (mst cmmnly the additinal piids were paid fr in cash). Cncurrent drug abuse diagnsis in patient s electrnic prfile = 56 patients (39%). 2

3 P&T Recmmendatins frm their May 2012 meeting included: Lng-Acting Narctic Analgesics Tighten up definitin f failure f a preferred agent beynd just a prir fill f preferred agent. Recmmended evaluating mrphine equivalent dsing when requests received t switch piids. Tighten up criteria fr fentanyl transdermal patches currently nly requires failure f ne ral preferred lng acting piid. PROP Physicians fr Respnsible Opiid Prescribing Jane Gennrich, Pharm.D. Dr. Gennrich presented an verview f PROP Physicians fr Respnsible Opiid Prescribing Their missin statement is: Our missin is t reduce mrbidity and mrtality resulting frm prescribing f piids and t prmte cautius, safe and respnsible piid prescribing practices. They have submitted a petitin t the FDA t request changes tpiid analgesic labels: 1. Strike the term mderate frm the indicatin fr nn-cancer pain. 2. Add a maximum daily dse, equivalent t 100 milligrams f mrphine fr nncancer pain. 3. Add a maximum duratin f 90 days fr cntinuus (daily) use fr nn-cancer pain. The fllwing tpics were reviewed as part f the PROP prgram: Review f FDA REMS Recmmendatins fr extended release and lng acting piids July 9, 2012 which includes: Training fr Prescribers Updated medicatin guides fr cnsumers Assessment/Auditing f prescriber educatin Guidelines fr cmpanies n what t include in prescriber educatin Assessment f prescriber s understanding f risk infrmatin Assessment whether the REMS is adversely affecting patient access t necessary pain medicatin. The department is hping t send a department representative t the Natinal Summit n Opiid Safety which will be held in Seattle n Oct 31 Nv 1, Prpsed Idah pharmacy department activities regarding lng-acting piid criteria: Ask fr chart ntes n all patients currently receiving mre than 500mg mrphine equivalents daily fr review by pharmacist/medical directr. Send a cpy f Bard f Pharmacy reprt n patients paying cash fr additinal dses t the prescriber. 3

4 Aliskiren DUR The FDA published a safety annuncement n April 20, 2012 warning f the pssible risks when using aliskiren cntaining prducts with ACEIs r ARBs in patients with diabetes r kidney impairment. A reprt was run t identify patients wh had received an aliskiren cntaining prduct within the last 90 days. These prfiles were then reviewed by Idah Medicaid pharmacists t determine if these patients were cncurrently n an ACEI r an ARB. Letters were sent t 17 prescribers cncerning 13 patients (in several cases, the ACEI/ARB was prescribed by a different prescriber than the aliskerin) n 4/30/2012. Fur (4) respnses have been received as f 8/10/2012 (24% respnse rate). Luprn DUR Jane Gennrich, Pharm.D. Reasn fr the DUR prject Received prir authrizatin request fr Luprn fr a 14 year ld genetically male patient wh is requesting a gender change t female. The request was denied as nt medically necessary. Previusly Luprn claims wuld pay with prir authrizatin nt needed. Idah Medicaid has nw instituted prir authrizatin requirements fr Luprn. Prfiles were reviewed fr patients with paid claims fr Luprn between 9/1/2011 and 3/31/3012 (n=25), 15 patients were children with sexual preccity and 10 patients were wmen with endmetrisis. Prir authrizatin apprvals were entered fr all current patients wh are still receiving Luprn therapy. The department will institute an aut-pa rule s that claims fr children with preccius puberty and wmen with endmetrisis will pay at pint f sale if the applicable diagnsis is in the patient s electrnic prfile. Therapeutic criteria fr payment fr Luprn include the fllwing diagnses: sexual preccity in children, endmetrisis, breast/varian/prstate cancer. Ciprflxacin DUR Jane Gennrich, Pharm.D. The Pharmacy Unit was requested t analyze why (e.g. what type f infectin) ciprflxacin is prescribed fr pediatric Idah Medicaid patients. Ciprflxacin is FDA apprved fr pediatric patients 1-17 years f age with cmplicated urinary tract infectins and pyelnephritis due t E cli and fr pediatric patients (age nt specified) with inhalatinal anthrax. Retrspective DUR was dne n patients under 16 years f age with ne r mre paid claims between 2/1/12 and 4/30/ patients were identified with a mean age f Please refer t the slides fr a breakdwn f infectin type. The DUR bard deferred making a recmmendatin until a pediatrician culd evaluate the data. 4

5 Synagis DUR Jane Gennrich, Pharm.D. Review f the seasn: Medical claims = $274,881 & Pharmacy claims = $1,362,627 Idah Medicaid s prir authrizatin criteria is the same as the current AAP (American Academy f Pediatrics) recmmendatins. All patients with paid medical claims fr Synagis did have prir authrizatin apprval thrugh the Pharmacy Unit. Mre than half f these patients did nt have their prir authrizatin request frms marked crrectly t indicate that the drug was ging t be billed as a medical claim rather than as a pharmacy claim. Several ptential billing inaccuracies were identified such as (1) patients being billed fr up t 7 dses when the medical claims and the pharmacy claims were cmbined fr a single patient and (2) incnsistent dsages billed (e.g. wuld expect dses t increase with age and increasing weight and nt decrease ver time). The DUR cmmittee recmmended requesting chart ntes and administratin recrds t evaluate fr billing errrs. In July 2012 the AAP Red Bk updated their Synagis Prphylaxis recmmendatins: (1) multiple births yunger than 1 year f age d nt qualify as fulfilling the yung siblings risk factr fr infants with gestatinal age between 32 weeks, 0 days and 34 weeks, 6 days and (2) sectin added n infants with cngenital abnrmalities f the airway r neurmuscular disease. Grwth Hrmne DUR Backgrund: Idah Medicaid s Pharmacy & Therapeutics Cmmittee requested that the DUR Bard lk at the utilizatin numbers fr the Grwth Hrmne class t determine if savings culd be accmplished if patients were switched frm a nnpreferred t a preferred agent. Gentrpin, which is a nn-preferred agent, is still being used by 16 patients wh have been grandfathered. The DUR bard recmmended that several endcrinlgists be cntacted by Idah Medicaid t discuss the issues with switching these patients ver t a preferred agent. Psychtrpic Medicatins in Fster Children Dr. Eide discussed data n psychtrpic medicatin use in fster children wh are enrlled in Idah Medicaid. Cmparisn f Idah Medicaid statistics t five states in the GAO Study. Percentage f children prescribed psychtrpics by state Fster children percentage Nn-fster children percentage Rati f fster t nn-fster children 5

6 Ttal number f fster children and nn-fster children frm Percentage f fster and nn-fster children receiving psychtrpic medicatins between In summary: The trends include increased use f psychtrpic medicatin in fster children in cmparisn t a stable percentage f use in nn-fster children. She then presented a detailed analysis f the use psychtrpic drugs in 2011, including: Percent f fster and nn-fster children psychtrpic use by drug class fr fur majr classes f drugs ADHD, Antidepressants, md stabilizers and Atypical antipsychtics. An analysis f which prescriber types are prescribing these drugs in Idah as well as reginal prescriber variatin. Age distributin by percent f prescriptin vlume by age was graphed. The fllwing red flags fr Fster Children and Psychtrpic Drugs have been identified: Five r mre psychtrpic medicatin prescribed cncmitantly. Tw r mre cncmitant antidepressants. Tw r mre cncmitant antipsychtic medicatins. Tw r mre cncmitant stimulant medicatins. Lng-acting plus shrt-acting cncmitantly is acceptable Three r mre cncmitant md stabilizers. Psychtrpic plypharmacy (tw r mre agents) fr a given mental disrder being prescribed befre trying mntherapy. Dr. Eide then summarized the steps in the implementatin f the Red Flags prcess t imprve drug utilizatin in these patients. The steps include: Retractive evaluatin Identificatin f utliers Prfile review DUR Bard Interventin using targeted educatin. Re-evaluatin f bth individuals and the verall ppulatin. Further Actin: Initiate Pint f Service edits bth: Infrmatinal (sft/pharmacist verride) and Hard stp edits. Dr Eide then presented an analysis f five fster care children with five r mre psychtrpic medicatins (the first red flag). The study parameters included: Fster children with 5 r mre distinct behaviral health drugs The service dates were between 11/1/2011 and 4/30/2012 (6 mnths) 6

7 The Mental Health Drug List included: Stimulants itemized by drug name. Other ADHD Treatments such as atmxetine, clnidine, guanfacine, buprpin, imipramine, nrtriptyline. Antidepressants such as SSRIs and SNRIs Md Stabilizers including carbamazepine, divalprex, lithium and lamtrigine. Secnd Generatin (atypical) Antipsychtics First Generatin (typical) Antipsychtics The five patients were then reviewed by their mental health diagnses listings and prescriptin drugs prescribed including the duratin f time fr use f each drug. It was recmmended that cmplete medical recrds be requested frm prescribers fr further clinical analysis. The study f drug usage in the fster child ppulatin will cntinued t be reviewed by prpsed studies in future quarters. Study Prpsals fr Next Quarter Prpsed Studies fr Next Quarter: 7 P & T Cmmittee Narctic Analgesic Studies cntinued. Leuktrienes vs inhaled crticsterids in children with asthma. Use f Psychtrpic Medicatins in Fster Children Tw r mre cncmitant antidepressants. Migraine Preventin Prphylaxis Utilizatin in Chrnic Triptan Utilizers Tpiramate PA, Medical Claim and Triptan Use Mismatch IVIG Intravenus Immune Glbulin Currently prir authrizatin is nt needed fr either an utpatient prescriptin (under $7500) r a claim n the medical side. The pharmacy staff is in the prcess f sending ut letters t gather medical infrmatin including: Diagnsis Dsing regimen Respnse t therapy The staff will review IVIG infrmatin at the Octber 2012 DUR Meeting. A future questin t answer: Shuld IVIG require prir authrizatin?

8 PrDUR Quarterly Reprt DUR Newsletter Dr. England reviewed the prspective DUR reprt fr PrDUR messaging fr the prir quarter. The Spring Newsletter was included in the packet. Tpics t be included in the summer newsletter include infrmatin n Psychtrpic Use in Fster Children and Narctic Analgesics. Medicaid Update Dr. Eide reviewed the prir quarter activity in the Medicaid pharmacy department. The primary extracurricular activities recently have invlved a series f OIG audits fr rebates and an upcming OIG Security Audit. Adjurn, 2:15 PM Next Meeting: Octber 18, :00 AM 8