No Need to Tax the Sick: Clinical Guidelines for Rofecoxib as an Alternative Effective Method to the Copayment Policy in the Advent of Increasing Pharmaceutical Expenditures

Military Medicine, Nov 2004 by Rosen, Yitzhak, Yachelevich, Naomi, Benedek, Paul, Grotto, Itamar, Et al

Background: Over the last few years, major health care systems have been trying to control increasing pharmaceutical expenditures by a variety of methods, such as the controversial copayment policy, as essential health expenditures were being jeopardized. Objective: To analyze the regulatory intervention of preauthorization on a rofecoxib model in the medical corps of the Israeli Defense Forces (IDF) in terms of indications for prescription, consumption, and cost. Interventions: Guidelines established by the medical services branch based on current literature and communication with diverse specialists and hospitals were implemented by a general practitioner who checked each rofecoxib prescription that was written for IDF personnel by a specialist. The intervention was initiated in November 2000 and continued until August 2001 and after the study. Design: The study was divided into two parts. The first part was a retrospective monthly, preintervention analysis of computerized medical records of IDF personnel (N = 247) for whom rofecoxib was prescribed. The second was a prospective monthly, postintervention analysis of filled-out guideline forms (N = 250) of approved rofecoxib prescriptions. Participants: Patients were IDF personnel, age 18 to 45, treated in military and civilian outpatient clinics for whom rofecoxib was prescribed. Setting: The study took place at the Medical Service Branch of the IDF between August 2000 and August 2001. Results: We demonstrated a significant decrease in average monthly consumption (43.0%) and estimated monthly expenditures (40.84%) of rofecoxib, as well as significant shifts (p

Introduction

Over the last few years, controlling pharmaceutical expenditures has become an important issue to health care systems, as these expenditures are on a rising trend.1-4 Among the reasons for this increase is an increased use of new and more expensive medications. In addition, prescribing doctors lack effective demand-side measures such as specified budgets and a generics market.1 6 Controlling these expenditures has been deemed a necessity because essential health expenditures were being jeopardized. Many systems have been trying to keep these expenditures under control by a variety of measures.W4 For example, the measures of the Spanish government include control of prices, introduction of a "negative list" of drugs no longer reimbursed, increased cost sharing, and the introduction of overall budgets for pharmaceutical expenditures.4

Controlling pharmaceutical expenditure by a copayment policy has been used by several health care systems. Studies suggest that this policy reduces the use of essential drug consumption and may cause more harm than good, especially for those who cannot afford the payments.3,5,7-14 In the Israeli Defense Forces (IDF), soldiers and officers have no copayment responsibility: the drug is totally reimbursed or not.

Rofecoxib is a selective inhibitor of the cyclooxygenase-2 (COX-2) enzyme. It has been used for pain control and as an anti-inflammatory agent.15-18 Among the rheumatic conditions, rheumatoid arthritis and osteoarthritis are two conditions that showed promising results with rofecoxib.15,18 Rofecoxib is an appropriate choice when adequate analgesia is not achieved by acetaminophen or traditional nonsteroidal anti-inflammatory drugs (NSAIDs), or when patients are at risk for adverse gastrointestinal side effects.15-18

Although NSAIDs are cheaper than rofecoxib, adverse gastrointestinal side effects limit their use. Pellissier et al.15 showed that rofecoxib has been shown to be more cost effective than NSAIDs while taking account the costs of adverse gastrointestinal side effects caused by the latter in certain populations.

The aim of this study was to assess a regulatory intervention involving clinical guidelines for the prescription of rofecoxib in terms of conditions for which rofecoxib was prescribed, estimated costs, and consumption. The results of assessment reflect the periods before and during the intervention period.

Methods

Patients

Patients were IDF personnel age 18 to 45. The patients suffered from a variety of diseases, including lower back pain, rheumatoid arthritis, spondyloarthropathies, and connective tissue disorders. They were treated in civilian and military outpatient clinics. All were treated with rofecoxib.

Setting

The study was conducted at the Medical Services Branch between August 2000 and August 2001.

Data Collection

Before the intervention, data were gathered from August 2000 through August 2001 by two different computerized networking services. One service provided continuous data on medication consumption and costs. The second provided data on patient visits, including a log code for the diagnosis based on the International Classification of Primary Care, treatment given, and allergies.19 These data were retrospectively used for the preintervention sample (JV = 247).

Once the intervention was initiated, forms containing specified data for each IDF personnel receiving an approved rofecoxib prescription were analyzed. These data were prospectively used for the postintervention sample (N = 250).