Hannah E. Cook, PharmD1, Rachel B. Britt, PharmD1, Mohamed Hashem, PharmD1, Sara R. Britnell, PharmD1, Vera Pervitsky1, Darshan Kothari, MD2; 1Durham Veterans Affairs Medical Center, Durham, NC; 2Duke University School of Medicine, Durham VA Medical Center, Durham, NC
Introduction: Pancreatic enzyme replacement therapy (PERT) is recommended for patients with exocrine pancreatic insufficiency (EPI). Prescribing information recommends pancrelipase to be dosed between 500-2500 units/kg/meal. Because PERT can be expensive, prescriptions for unindicated reasons and/or inappropriate doses can lead to unnecessary healthcare costs. Thus, we aimed to characterize the prescribing practices of pancrealipase at a single veterans affairs medical center (VAMC) and determine the burden of cost to the VAMC for inappropriate prescriptions. We hypothesized the VAMC was incurring excessive costs for prescriptions with non-labeled indications and dosing outside of the recommended range. Methods: We performed a retrospective review of all active prescriptions for pancrealipase at a single VAMC in March 2020. We collected data on prescription doses, formulations and indications as well as prescriber specialty data. The approved indication for PERT was confirmed EPI as defined by a fecal elastase less than 200mcg/g or 72 hour fecal fat greater than 7g/24 hours or presumed EPI from an associated diagnosis of CP as confirmed by radiographic and/or endoscopic ultrasound evidence or diagnosis of cystic fibrosis. Our primary outcome was number of veterans on appropriate dosing of pancrealipase for an approved indication. Data was reported using descriptive statistics. Using the relative cost for prescriptions incurred by our VAMC, we calculated the burden of cost for inappropriate prescriptions. Results: In the study period, 145 patients received pancrelipase prescriptions, of which 21 patients (14.5%) had laboratory data to support a diagnosis of EPI. In the remaining 124 patients, only 24 patients had evidence of CP. Thus 100 patients (69.0%) did not have an approved indication for PERT (figure). Further, of the patients on PERT for EPI and/or CP, an additional 17 patients were under-dosed. In total, 117 patients (80.7%) were on pancrealipase for an unindicated reason and/or inappropriate dose, costing the VAMC an annualized $236,700. Current prescriptions were dosed appropriately by 87% (27/31) of GI providers and 28% (27/97) of PCPs. Discussion: Our study demonstrates that at a single VAMC, there is excessive inappropriate pancrealipase prescriptions, costing the health center >$230,000 annually. These findings are likely generalizable to other medical centers with a single payer model. Further work is needed to demonstrate improvement in prescribing practices that reduces costs.
This graphic shows the breakdown of patients that had documented EPI and/or CP out of all patients on pancrelipase in March 2020 at a single healthcare system. The graphic then separates out the patients that were on recommended dosing per prescribing information.
Disclosures: Hannah Cook indicated no relevant financial relationships. Rachel Britt indicated no relevant financial relationships. Mohamed Hashem indicated no relevant financial relationships. Sara Britnell indicated no relevant financial relationships. Vera Pervitsky indicated no relevant financial relationships. Darshan Kothari indicated no relevant financial relationships.