Impact of combination therapy on managed care. Based on a presentation by Lisa Latts, MD, MSPH.
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The major objectives of managed care are particularly applicable to hypertension, a very common disease that affects about 30% of the adult population. Although managed care organizations know that adequate blood pressure control has a considerable impact on reducing hypertension-related morbidity and mortality, managed care is, at present, doing a generally poor job of monitoring antihypertensive therapy. One of the major reasons for this is the difficulty in gathering the necessary data from administrative sources; only chart review, which is very costly and very time consuming, can provide the data needed. The value of disease management lies in its capacity to optimize clinical and economic outcomes as well as to improve service and quality of life, using inputs such as cost, time, clinical resources, and patient satisfaction. Disease management programs are instituted because they can lead to improved quality of life and reduced costs. While the focus in managed care has traditionally been on promoting risk modification behavior, providing patient education, and encouraging medication compliance, the treatment of hypertension itself has not been a major focus in most disease management programs. Measuring the effectiveness of the hypertension treatment is, however, one of the proposed measures for the Health Plan Employer Data and Information Set (HEDIS 2000) to profile health plan quality. From a managed care perspective, the potential benefits of combination therapy for hypertension include improved blood pressure control and improved patient compliance as a result of needing fewer pills and experiencing fewer side effects with low-dose therapy. Among the obstacles to combination therapy in the managed care setting are the addition of the combinations onto a formulary and lack of acceptance among physicians. Fixed-dose combination therapy with a calcium channel blocker and an angiotensin-converting enzyme (ACE) inhibitor can potentially reduce pharmacy costs if given to patients who are taking both drugs independently and to patients who are taking a calcium channel blocker but should probably also be taking an ACE inhibitor (e.g., patients with diabetes or congestive heart failure). A mini-pharmacoeconomic analysis based on claims data over a 6-month period from HMO Colorado, a health maintenance organization, shows that switching patients on dual therapy with a calcium channel blocker and an ACE inhibitor to 1-pill combination therapy with both agents can result in substantial cost savings. (+info)
Pharmacoeconomics of emerging therapies for rheumatoid arthritis. Based on a presentation by Arthur Kavanaugh, MD.
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Rheumatoid arthritis is a costly disease. Patients with this condition not only utilize substantial medical resources, but also incur high indirect costs in the form of work disability. These indirect costs are generally much greater than the direct costs. Therefore, a new therapy that is able to control this disease more effectively may be cost effective, even if the direct costs of the therapy itself are high. From a cost-analysis point of view, patients with refractory disease may be good candidates for a new therapy. All costs, direct and indirect, should be considered, and a global, long-term perspective on patient care should be taken. One way to estimate the worth of a therapy based on its ability to improve how patients feel would involve a utility or quality-of-life analysis. (+info)
Implementing effectiveness research and improving care for schizophrenia in real-world settings.
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OBJECTIVE: To review recent advances in medication practices and standards of care in the treatment of schizophrenia and examine the disparity between the knowledge base and clinical practice. DATA SOURCES: Key literature on medication practices, novel pharmacotherapies, and the evolution of practice guidelines for schizophrenia were reviewed. DISCUSSION: Emerging data demonstrate a lack of consistent application of current knowledge and best practices, in part due to major structural inconsistencies in the public mental health system. Implementation of results from effectiveness research as well as the incorporation of practice guidelines may help bridge this gap. CONCLUSION: As standards of care for schizophrenia are developed, the following issues will need particular attention: coordination with the criminal justice system, comprehensive treatment of comorbid illnesses, outcomes based on symptoms in all domains, and continuous and integrated collection of data to produce rational cost justification. (+info)
Valuing Viagra: what is restoring potency worth?
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CONTEXT: The use of Viagra (sildenafil) (Pfizer, New York, New York) for treating impotence has increased dramatically. However, the cost of the drug and philosophical questions about what defines a medical condition have sparked controversy over whether insurance policies should cover impotence treatment. COUNT: The utility of life with impotence at which Viagra meets the conventional criterion for cost-effectiveness (i.e., < $50,000 per quality-adjusted life-year [QALY]). CALCULATION: We solved the following equation for utility of life with impotence: [formula: see text] RESULTS: Assuming that Viagra is used twice a week and that it costs $10 per pill, the utility of life with impotence would have to be less than 0.98 (compared with quality of life without impotence) for Viagra to meet the conventional criterion for cost-effectiveness. For patients using Viagra once or three times per week, the corresponding threshold utilities for impotence were 0.99 and 0.97, respectively. CONCLUSIONS: For men whose quality of life is sufficiently diminished by impotence, Viagra would be considered cost-effective relative to other commonly used health interventions. (+info)
A cost analysis on the pattern of asthma prescribing in the UK.
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There is a need to establish the proportion of adult asthmatics at each step of the recommended asthma management guidelines, the cost of their prescribed treatment, and a revised cost of treatment assuming patients who were suboptimally controlled were moved up a step. Actual prescription and cost figures and a theoretical projection of an ideal scenario was calculated from a sample of general practices in Great Britain from the Doctors Independent Network. They comprised 102 nationally distributed practices and 17,206 adult patients with a diagnosis of, and prescription related to, asthma recorded between October 1993 and March 1994. Ninety-one per cent of patients received treatment within a recognized step of the guidelines. Of these, 80% were at steps 1 and 2. Employing excess inhaled beta-agonist use as a proxy for control of asthma, between 55% and 69% of patients at Steps 1-3 should receive treatment at a higher step. This could lead to an increased expenditure of up to Pound Sterling 4.66 per adult patient per month. This would imply a rise in the annual UK cost of antiasthma prescriptions for adults from Pound Sterling 388m to a possible Pound Sterling 533m. The United Kingdom Government audit commission has suggested that current expenditure on asthma treatment appears to be insufficient. Using an entirely different approach this study has confirmed that a significant increase in asthma prescribing costs is likely to be needed if optimal control of asthma is to be achieved. (+info)
A short-term cost-of-treatment model for type 2 diabetes: comparison of glipizide gastrointestinal therapeutic system, metformin, and acarbose.
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OBJECTIVE: To compare, from a managed care perspective, the 3-year costs of 3 first-line monotherapy strategies in type 2 diabetes patients: glipizide gastrointestinal therapeutic system (GITS), metformin, and acarbose. STUDY DESIGN: A Markov model, with a Monte Carlo simulation, was developed to compare the costs to achieve full glycemic control (hemoglobin A1c of < or = 7%) with each first-line strategy. PATIENTS AND METHODS: The patient population for the model was assumed to be all newly diagnosed type 2 diabetes patients eligible for monotherapy with an oral agent. Each monotherapy could be succeeded by add-on treatments. The model included the costs of routine medical care and supplies, medication, adverse events, and treatment failures. RESULTS: Using a Monte Carlo simulation, the mean 3-year cumulative costs per patient were $4971, $5273, and $5311 for glipizide GITS, metformin, and acarbose first-line strategies, respectively. The main cost drivers were drug prices. Mean 3-year cost savings for first-line glipizide GITS were $301 over metformin and $340 over acarbose. Between 83% and 85% of all simulations showed cost savings with glipizide GITS compared with the other agents. CONCLUSIONS: The model suggests first-line monotherapy with glipizide GITS should result in desirable short-term economic benefits for managed care. Because the model incorporates recommended glycemic goals and performed well in sensitivity analyses, it should be applicable to a variety of clinical practices and useful for economic assessments of new therapies. Results of this model should be verified prospectively in typical care settings. (+info)
HIV infection in adults: a therapeutic update.
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AUDIENCE: This article is designed to update physicians, pharmacists, nurses, and other healthcare providers on therapeutic advances concerning human immunodeficiency virus (HIV) infection. GOALS: To provide a review of the pathophysiology of HIV infection as well as an update on current guidelines, acute infection, medications, adherence, and monitoring. Recommendations regarding treatment in pregnancy and postexposure prophylaxis will also be discussed. Lastly, the impact on managed care will be considered. Treatment of and prophylaxis against opportunistic infections is not reviewed in this article. OBJECTIVES: 1. Review the basic pathophysiology of HIV. 2. Discuss the implications of acute HIV infection. 3. Update guidelines concerning initiation of drug therapy and appropriate monitoring of drug therapy. 4. Discuss ways to increase adherence. 5. Discuss dosing, adverse effects, and drug interactions concerning the current medications available for the treatment of HIV. 6. Review treatment recommendations in pregnancy. 7. Review treatment recommendations for postexposure prophylaxis. 8. Discuss the impact of HIV infection on managed care. (+info)
Therapeutic substitution and therapeutic conservatism as cost-containment strategies in primary care: a study of fundholders and non-fundholders.
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BACKGROUND: General practice (GP) fundholders contained prescribing costs by restricting the rise in volume of prescribing and by increasing generic prescribing. It is uncertain whether they used more sophisticated approaches to medicine choice in attempts to contain costs. AIM: To examine whether fundholding practices have adopted medicine-specific strategies to contain prescribing costs--i.e. switching to less expensive but equally effective medicines or resisting the uptake of newer more expensive medicines--by examination of the prescribing of ulcer-healing and antidepressant medicines in the period before and after practices became fundholders. METHOD: Comparison of prescribing data of 52 fundholding practices before fundholding and after fundholding with that of matched non-fundholding practices. Measures examined were prescribing costs (net ingredient cost in each therapeutic area per ASTRO-pu); prescribing volume (defined daily doses per ASTRO-pu); the proportion of all ulcer-healing medicines prescribed as cimetidine, ranitidine, nizatidine, and as proton pump inhibitors; and the proportion of all antidepressant medicines prescribed as selective serotonin re-uptake inhibitors. RESULTS: In comparison with non-fundholding practices, fundholders increasingly prescribed less expensive medicines (cimetidine and nizatidine) within the class of histamine2 receptor antagonists. However, fundholders adopted proton pump inhibitors or selective serotonin re-uptake inhibitors at the same rate as non-fundholders. CONCLUSION: Fundholders have used therapeutic substitution with medicines of equal effectiveness to contain prescribing costs. There is no evidence that fundholders have been slower than non-fundholders to use newer, more expensive medicines. (+info)