Managed Care - December 2008 - (Page 44)

fects, which is more than 3 times the rate initially reported by the same authors. Again in this article, authors reported therapy cost of $265 per day compared to $976 per day in the hospital (Buttino 2000). The implication is that patients would have the same length of stay in the hospital, but this is not normally the case (Naef 1995). The most recent industry-sponsored level III peer-reviewed descriptive case series appeared in a managed care publication in 2004. This observational trial studied 428 women and analyzed the incidence of treatment failure, hospitalization/ER visits, degree of ketonuria, and pregnancy-unique quantification of emesis and nausea (PUQE) score at the program start/stop. The average treatment duration reported was 26.9 days, and the price per day was $145. Therefore, the average spent on each patient was $3,900 (26.9 days X $145 per day). Symptoms of NVP were improved for 89.3% of patients, but 10.7% were switched to continuous subcutaneous ondansetron therapy that cost health plans approximately $380 per day, or a total of $10,222, applying the reported average length of stay. This trial reported a blended rate that included patients started on metoclopramide and switched to ondansetron, but in clinical practice it is not uncommon to start therapy with ondansetron and remain on the drug for the full duration of therapy. This study demonstrated the PUQE score decreased significantly comparing initiation of therapy to completion of therapy as would be expected with most NVP treatments. Correspondingly, ketonuria decreased, as did hospital and ER visits. No control group was used as a comparison cohort, so it is impossible to determine how well this therapy worked compared to other lower cost and more convenient options such as outpatient phenergan IV, PO, or ondansetron ODT (orally disintegrating tablet) (Lombardi 2004). These reports do not constitute enough evidence to support health plans paying millions of dollars for continuous subcutaneous antiemetic use before a well designed randomized controlled trial is conducted, with sufficient sample size to demonstrate a clinically meaningful difference and cost effectiveness. The cost assumption that NVP patients would spend the same number of days in the hospital as on home care is debatable because these patients are traditionally treated episodically and do not require extended hospitalization. Health plans should consult medical management to design care paths to attempt lower cost alternatives before spending $4,000 to $11,000 per patient to arrest NVP. Metoclopramide and ondansetron are available in oral formulations. Ondansetron ODT represents an option that would save considerable expense if it were tried and failed before approving either continuous subcutaneous metoclopramide or continu- ous subcutaneous ondanse tron therapy. Subcutaneous ondansetron The medical evidence regarding continuous subcutaneous ondansetron consists of only one level III uncontrolled case series that is published and peer-reviewed — the study previously described in which patients who failed continuous subcutaneous metoclopramide were then administered ondansetron. In all the observational trials examining continuous subcutaneous ondansetron and metoclopramide, the questionable assumption is that the patient would have spent every day on continuous subcutaneous administration of antiemetic therapy in the hospital. But in a well designed study that contained actual cost of treatment, both the home care group and even the hospital group were significantly less expensive compared to the most recent published continuous FIGURE 1 Mean cost per patient for management of nausea and emesis of pregnancy $5,000 $4,432 $4,000 $3,000 $2,701 $2,000 $1,000 $701 0 Continuous SQ Antiemetic1 Source: 1Lombardi DG, et al. 2Naef RW III, et al. Hospitalization for HG2 Home care for HG2 44 MANAGED CARE / DECEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - December 2008

Managed Care - December 2008 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor ICD-10 Offers Huge Opportunity, Challenge Part D at a Crossroads Plans Can Weather the Financial Crisis DM vs. Medical Home? Tackle Prediabetes Reasonable Approach to Morning Sickness Formulary Files Tomorrow's Medicine Outlook

Managed Care - December 2008

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