A nurse-delivered advice intervention can reduce chronic non-steroidal anti-inflammatory drug use in general practice: a randomized controlled trial.
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OBJECTIVE: To find out whether a nurse-delivered educational package can reduce chronic oral non-steroidal anti-inflammatory drug (NSAID) usage in general practice. METHOD: A prospective randomized controlled trial with assessment of economic cost/benefits was carried out in five general practices in Nottinghamshire with computerized prescribing systems, representing a mix of rural/urban and fundholding/non-fundholding practices. Patients suffering from non-malignant, non-inflammatory musculoskeletal pain received repeat prescriptions for oral NSAIDs. Two hundred and twenty-two patients were randomized to a control group (simple advice regarding NSAID use) or an intervention group (asked to withdraw their NSAIDs and employ appropriate alternative drug and non-drug therapies). All advice was supported by patient literature and delivered by a nurse practitioner trained in musculoskeletal assessment. The primary outcome measure was change in NSAID use 6 months after the intervention. Secondary outcome measures were changes in health and quality of life (SF-36 and EQ-5D questionnaires) and drug, health service and patient costs. RESULTS: An extra 28% of patients in the intervention group either stopped taking oral NSAIDs or reduced dosage by > or =50% at 6 months compared with controls. There was no detrimental effect on health and well-being. Oral NSAID prescription costs were significantly lowered in the intervention group but not in the control group. A non-significant increase in total drug prescription costs occurred in both groups. CONCLUSIONS: Nurse-based intervention can reduce chronic NSAID usage and costs in primary care and would be cost-effective if maintained in the long term. This intervention package would be readily applicable in primary care. (+info)
Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation.
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BACKGROUND: The development of low-molecular-weight heparins (LMWHs) has made it possible to shift treatment of deep vein thrombosis (DVT) from inpatient to outpatient settings, thereby saving costs and improving patient quality of life. OBJECTIVE: To quantify the economic benefits of early discharge of patients treated for DVT with LMWH using data pooled from multiple healthcare plans. METHODS: Data sources were integrated medical and pharmacy claims paid by 37 US health plans (the PharMetrics Integrated Outcomes Database, PharMetrics, Inc., Watertown, MA). Hospitalized patients discharged with a diagnosis of DVT were selected and grouped according to the anticoagulation therapy they received after discharge. Outcomes and costs of DVT treatment were assessed over a 1-year period. RESULTS: Patients discharged on the LMWH enoxaparin and warfarin spent 2.6 fewer days in the hospital than those discharged on warfarin alone (P< .0001), resulting in cost savings of $1911 per patient. Mean costs of outpatient management of DVT, including pharmacy and medical services, were $901 higher in the enoxaparin/warfarin cohort, but rate of readmission was lower (6.7% versus 9.0%; P < .05) and hence subsequent inpatient costs were reduced by $140 per patient. Total cost savings in the enoxaparin/warfarin cohort, net of higher outpatient costs, were $1151 per patient. CONCLUSIONS: Outpatient anticoagulation therapy for DVT with enoxaparin and warfarin is associated with earlier hospital discharge, fewer readmissions, and lower total DVT-related costs compared with warfarin monotherapy. (+info)
Evaluating early dementia with and without assessment of regional cerebral metabolism by PET: a comparison of predicted costs and benefits.
(75/780)
Evaluating dementia in patients with early symptoms of cognitive decline is clinically challenging. Growing evidence indicates that appropriate incorporation of PET into the clinical work-up can improve diagnostic and prognostic accuracy with respect to Alzheimer's disease (AD), the most common cause of dementia in the geriatric population. The precise diagnostic role of PET and its economic impact in this context, however, have not been systematically examined previously. METHODS: We compared the relative value of 2 strategies for assessing whether early AD is responsible for cognitive symptoms in geriatric patients: (a) a conventional approach, based largely on establishing clinical criteria for the presence of dementia and excluding non-AD etiologies that could contribute to the patient's symptoms, and (b) a proposed approach using PET to examine regional cerebral metabolism and look for characteristic patterns of abnormal metabolism. The total costs (measured in dollars) and benefits (measured in number of accurate diagnoses) of diagnostic testing and clinical outcomes accruing to each strategy were calculated using formalized tools of decision analysis. The primary outcome measure by which the strategies were compared was the ratio of costs to benefits obtained following each approach. RESULTS: Following the proposed approach led to improved accuracy in identifying early AD, without adding to the overall costs of diagnosis and treatment ($3,433 vs. $3,564 per patient approached by the proposed or conventional algorithm, respectively). The strategy making use of PET was associated with a reduced rate of false-negative and false-positive findings compared with the conventional approach (3.1% vs. 8.2% and 12.0% vs. 23.0%, respectively, at a prevalence of 51.6% in the studied symptomatic population) and a cost savings of $1,138 per correct diagnosis rendered ($4,047 vs. $5,185). The lower cost per unit benefit for the proposed strategy was maintained over a wide range of tested values for variables of sensitivity, specificity, costs of PET and long-term care, and varying approaches to the use of structural neuroimaging. CONCLUSION: Appropriate use of PET for evaluating early dementia in geriatric patients can add valuable information to the clinical work-up, without adding to the overall costs of evaluation and management, resulting in a greater number of patients being accurately diagnosed for the same level of financial expenditure. Thus, the opportunity exists for diminishing the morbidity of dementia economically, with earlier institution of more appropriate management in evaluated patients. (+info)
Cost savings in migraine associated with less chest pain on new triptan therapy.
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OBJECTIVES: This article constructs an economic model to estimate cost of chest-pain-related care in migraine patients receiving almotriptan 12.5 mg compared with those receiving sumatriptan 50 mg. STUDY DESIGN: This population-based, retrospective cohort study used data from the MEDSTAT Marketscan database (Ann Arbor, Michigan) to quantify incidence and costs of chest-pain-related diagnoses and procedures. After a 6-month exclusion period, the study used a pre-post design, with baseline and treatment periods defined, respectively, as 5 months before and after receiving sumatriptan therapy. An economic model was constructed to estimate annual cost savings per 1,000 patients receiving almotriptan instead of sumatriptan as a function of differing rates of chest pain. Annual direct medical cost avoided was calculated for a hypothetical health plan covering 1 million lives. RESULTS: Among a cohort of 1,390 patients, the incidence of chest-pain-related diagnoses increased significantly (43.6%) with sumatriptan, from 110 during the baseline period to 158 during the treatment period (P= .003). Aggregate costs for chest-pain-related diagnoses and procedures increased 33.1%, from $22,713 to $30,234. Payments for inpatient hospital services rose 10-fold; costs for primary care visits and outpatient hospital visits rose 53.1% and 14.4%, respectively. Payments for angiography increased from $0 to $462, and costs for chest radiographs and electrocardiograms increased 58.7% and 31.2%, respectively. Sumatriptan treatment was associated with a 3-fold increase in payments for services for painful respiration and other chest pain. The model predicted $11,215 in direct medical cost savings annually per 1000 patients treated with almotriptan instead of sumatriptan. Annual direct medical costs avoided for the health plan totaled $195,913. CONCLUSION: Using almotriptan instead of sumatriptan will likely reduce the cost of chest-pain-related care for patients with migraine headaches. (+info)
Compliance among pharmacies in California with a prescription-drug discount program for Medicare beneficiaries.
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BACKGROUND: Several states have developed prescription-drug discount programs for Medicare beneficiaries. In California, Senate Bill 393, enacted in 1999, requires pharmacies participating in the state Medicaid program (Medi-Cal) to charge customers who present a Medicare card amounts based on Medi-Cal rates. Because Medicare beneficiaries may not be accustomed to presenting their Medicare cards at pharmacies, we assessed the compliance of pharmacies with Senate Bill 393. METHODS: Fifteen Medicare beneficiaries who received special training and acted as "standardized patients" visited a random sample of pharmacies in the San Francisco Bay area and Los Angeles County in April and May 2001. According to a script, they asked for the prices of three commonly prescribed drugs: rofecoxib, sertraline, and atorvastatin. The script enabled us to determine whether and when, during their interactions with pharmacists or salespeople, the discounts specified in Senate Bill 393 were offered. Pharmacies at which the appropriate discounts were offered were considered compliant. RESULTS: The patients completed visits to 494 pharmacies. Seventy-five percent of the pharmacies complied with the prescription-drug discount program; at only 45 percent, however, was the discount offered before it was specifically requested. The discount was offered at 91 percent of pharmacies that were part of a chain, as compared with 58 percent of independent pharmacies (P<0.001). Compliance was higher in the San Francisco Bay area than in Los Angeles County (84 percent vs. 72 percent, P=0.004) and was higher in high-income than low-income neighborhoods (81 percent vs. 69 percent, P=0.002). A Medicare beneficiary taking all three drugs would have saved an average of $55.70 per month as compared with retail prices (a savings of 20 percent). CONCLUSIONS: Discounts required under California's prescription-drug discount program for Medicare beneficiaries offer substantial savings. Many patients, however, especially those who use independent pharmacies or who live in low-income neighborhoods, may not receive the discounts. (+info)
Impact of reference-based pricing for angiotensin-converting enzyme inhibitors on drug utilization.
(78/780)
BACKGROUND: Increasing copayments for higher-priced prescription medications has been suggested as a means to help finance drug coverage for elderly patients, but evaluations of the impact of such policies are rare. The objective of this study was to analyze the effect of reference-based pricing of angiotensin-converting enzyme (ACE) inhibitors on drug utilization, cost savings and potential substitution with other medication classes. METHODS: We analyzed 36 months of claims data from British Columbia for 2 years before and 1 year after implementation of reference-based pricing (in January 1997). The 119,074 patients were community-living Pharmacare beneficiaries 65 years of age or older who used ACE inhibitors during the study period. The main outcomes were changes over time in use of ACE inhibitors, use of antihypertensive drugs and expenditures for antihypertensive drugs, as well as predictors of medication switching related to reference-based pricing. RESULTS: We observed a sharp decline (29%) in the use of higher-priced cost-shared ACE inhibitors immediately after implementation of the policy (p < 0.001). After a transition period, the post-implementation utilization rate for all ACE inhibitors was 11% lower than projected from pre-implementation data. However, overall utilization of antihypertensives was unchanged (p = 0.40). The policy saved $6.7 million in pharmaceutical expenditures during its first 12 months. Patients with heart failure or diabetes mellitus who were taking a cost-shared ACE inhibitor were more likely to remain on the same medication after implementation of reference-based pricing (OR 1.12 [95% confidence interval, CI, 1.06-1.19] and 1.28 [95% CI 1.20-1.36] respectively). Patients with low-income status were more likely than those with high-income status to stop all antihypertensive therapy (OR 1.65 [95% CI 1.43-1.89]), which reflects a general trend toward discontinuation of therapy among these patients even before implementation of reference-based pricing. INTERPRETATION: Reference-based pricing in British Columbia achieved a sustained reduction in drug expenditures, and no changes in overall use of antihypertensive therapy were observed. Further research is needed on the overall health and economic effects of such policies. (+info)
Six hundred fifty-six consecutive explorations for primary hyperparathyroidism.
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OBJECTIVE: To review the outcomes of 656 consecutive parathyroid explorations performed by a single surgeon and to compare the results of conventional and minimally invasive parathyroidectomy (MIP) techniques. SUMMARY BACKGROUND DATA: Traditional surgery for primary hyperparathyroidism (HPTH) involves bilateral cervical exploration, which is usually accomplished under general endotracheal anesthesia. The MIP technique involves preoperative localization with sestamibi scans, surgeon-administered cervical block anesthesia, directed exploration through a small incision, intraoperative rapid parathyroid hormone assay, and discharge within 2 to 3 hours of surgery. METHODS: Six hundred fifty-six consecutive patients with primary HPTH underwent exploration between January 1990 and March 2001. RESULTS: MIP was used with ever-increasing frequency beginning in March 1998. Four hundred one procedures (61%) were performed using the standard technique and 255 patients (39%) were selected for MIP. The success rate for the entire series was 98%, with no significant differences comparing traditional and MIP techniques. The overall complication rate of 2.3% reflects 3.0% and 1.2% rates in the standard and MIP groups, respectively. MIP was associated with approximately a 50% reduction in operating time, a sevenfold reduction in length of hospital stay, and a mean cost savings of $2,693 per procedure, which represents nearly a 50% reduction in total hospital charges. CONCLUSIONS: A dramatic and sustained shift has occurred in the surgical treatment of primary HPTH: MIP has replaced traditional exploration for most patients. (+info)
New developments in influenza vaccine technology: a potential new prevention strategy for employers and managed care organizations.
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Influenza is still one of the most wide-reaching, deadly infectious diseases in the United States, with an estimated 54 million cases and 42,000 deaths in a typical year. At $14 billion, the annual cost of influenza is also enormous. More than 80% of that figure comes from so-called indirect medical costs-eg, the productivity loss that results when a person with influenza misses work. The economic cost makes the disease of special concern to employers, who bear the financial burden of such indirect costs, and to the managed care organizations that serve them. Although several therapies moderate the severity of influenza symptoms, prevention remains the best strategy for reducing the disease's morbidity and mortality, as well as the economic cost. Vaccines composed of inactivated (ie, killed) virus have been available for more than 50 years, and with millions of doses now administered, these inactivated vaccines have earned a strong safety record. When the viral strains contained in the vaccine match those circulating, efficacy against serologically defined infection can be as high as 88%. When the match is not good, however, the inactivated vaccine may have substantially lower efficacy. Another shortcoming is that the inactivated virus vaccine requires injection, which can deter compliance in those who have needle phobia or simply dislike getting shots. These concerns have fueled the development and application for licensing of a cold-adapted, live-attenuated influenza virus vaccine (CAIV), which is administered nasally and is not capable of causing disease. Compared with the inactivated vaccine, the CAIV may have superior efficacy and appears to have similarly minor systemic side effects. In addition, CAIV does not require injection and therefore does not cause local pain or tenderness when administered. This article summarizes recent studies of CAIV indicating that it is effective and safe. With its likelihood of enhanced compliance, its ease of administration, and its potentially superior efficacy, CAIV could play a significant role in influenza prevention. (+info)