Pharmacoepidemiology & Pharmacoeconomics

 The appropriate use of medications is becoming an increasingly central aspect of health care. Each year, the fruits of basic science research and biotechnology produce new therapeutic substances which hold the promise of major clinical benefit. However, drugs have also become the fastest-rising component of health care costs, with expenditures on medications set to outstrip hospital costs in many health care systems as the single most expensive aspect of medical care.

Simultaneously, concern is growing about the frequency and preventability of drug-induced illness. In 1998, the BWH Department of Medicine created the Division of Pharmacoepidemiology and Pharmacoeconomics to provide a setting for a wide range of activities related to the use and outcomes of medications, addressed from a variety of interdisciplinary perspectives.

The work of the Division can be divided into three broad categories:

Research mission

The Division carries forward the research agenda of the Program for Analysis of Clinical Strategies, initially begun by Dr. Avorn in 1979. Currently active research projects are described separately. They are designed to address questions such as the following:

• What effects do different non-steroidal anti-inflammatory drugs have on the risk of myocardial infarction?
• Which therapeutic strategies in the management of unstable angina are most likely to reduce the risk of myocardial infarction and death?
• Does reference pricing, a policy to limit prescription drug expenditures, indeed reduce spending, and what effects does the policy have on other health care utilization?
• What are the consequences of a formulary restriction of nebulized asthma/COPD medications on quality of life, functional status, and health care utilization in a randomized trial?
• How cost-effective are pharmaceutical approaches to the treatment of schizophrenia?
• How well do physicians treat osteoporosis and do patients comply with such therapies?
• Why do patients comply poorly with lipid-lowering medications and what are the implications of such behavior?
• How well do physicians conform to published guidelines for treatment of hypertension and what are the financial consequences of these prescribing patterns?

Training mission

Division faculty have created a new curriculum stream within the Department of Medicine training program that is designed to present house officers with information on cost-effective prescribing, as well as equip them with the analytic tools necessary to critically read and understand papers in the medical literature which relate drug benefits, risks, and costs. This approach is presently being extended to the Faulkner Hospital, BWH departments other than Medicine, and the Harvard Medical School curriculum.

The Division has also recently initiated a new program of academic detailing to improve antibiotic prescribing at BWH. In this peer-education based approach, medical residents are trained by infectious disease specialists to work with other house officers on more appropriate prescribing of targeted broad-spectrum antibiotics.

Improving drug utilization at BWH

The Division serves the Hospital's Pharmacy & Therapeutics committee in an advisory capacity in helping to assess drugs proposed for addition to the Hospital formulary, as well as monitoring the appropriateness of use of existing drugs. Educational interventions are then disseminated as needed to improve use of specific targeted agents. Currently, these include the following:

• Albumin
• G-CSF
• Erythropoietin
• Amphotericin
• Intravenous immune globulin