摘要:

This article describes research-based principles of successful treatment interventions in individuals with co-occurring disorders. These principles are placed in the context of an integrated model of service delivery that utilises a common language or treatment philosophy that makes sense from the perspective of both mental health treatment and substance disorder treatment fields.The article begins with an overview of the clinical and programmatic dilemmas faced by clinicians in treating these ‘dually diagnosed’ individuals and then enumerates 7 principles of treatment. These are:dual diagnosis is an expectation, not an exception, within any of the 4 subtypes of comorbidity (using a subtyping model based on high/low severity of each disorder);the most significant predictor of treatment success is the provision of an empathic, hopeful, continuous treatment relationship in which integrated treatment and care coordination are provided over time;within the context of this relationship, caretaking and case management are balanced with empathic detachment, empowerment and confrontation at each point in time;within this ongoing treatment context, both mental illness and substance disorder are considered primary, and integrated dual primary treatment is provided;both mental illness and addiction are examples of not just random primary disorders, but chronic biological mental illnesses which can be understood using a disease and recovery model;the model defines parallel phases of recovery, which themselves define phase-specific treatment interventions; as a result, there is no single correct intervention in this model. For each individual, the correct treatment must be matched to subtype, diagnosis, phase of treatment and extent of patient motivation and disability; andwithin a managed-care system, these interventions must be further individualised by a discrete level of care assessment for each disorder.These principles provide a template both for developing practice guidelines to determine individualised clinical treatment matching, as well as providing a template for large-scale system initiatives for the creation of comprehensive continuous integrated systems of care, and for assigning roles for each type of programme within those systems. These large systems initiatives are currently underway in several US states, and provide a laboratory for further research on this model.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

As physicians become more aware of the need to treat anaemia in their patients with cancer, they have to consider 2 treatment options: red blood cell transfusion or recombinant human erythropoietin [epoetin alfa; epoetin beta]. Healthcare systems are under increasing pressure to lower costs while maintaining quality of care; therefore, treatment of cancer-related anaemia requires a disease management strategy aimed at achieving optimal clinical and economic outcomes. Although blood transfusion is the traditional and fastest means of alleviating associated symptoms, possible complications include acute transfusion reactions, transfusion-related acute lung injury and bacteraemia. Long term complications comprise transmission of viruses and prions, alloimmunisation, immunomodulation and graft-versus-host disease. Despite the introduction of additional screening and sterilisation procedures, transfusions cannot be considered as completely safe, especially with the emergence of new infectious agents. Moreover, the clinical significance of a possible effect on immunocompetence, in terms of promoting tumour growth and risk of infection, remains to be resolved. Treatment with recombinant human erythropoietin increases haemoglobin levels and reduces the need for transfusion in patients with cancer-related anaemia. Trial data also show that recombinant human erythropoietin therapy is well tolerated by patients, and is useful in preventing and treating anaemia induced by cancer treatment.In terms of economics, the cost of blood transfusion is increased by indirect expenses associated with the treatment of complications and the subsequent need for laboratory testing or antigen-negative units. Its cost is likely to increase in the future with the introduction of additional screening procedures. While recombinant human erythropoietin may appear expensive at first sight, its cost effectiveness can be improved by measuring predictive response indicators such as haemoglobin and serum erythropoietin levels at baseline and after 2 weeks of treatment. For example, a US study reported that the effectiveness for each $US1 spent on standard care can be achieved with $US0.81 spent on recombinant human erythropoetin therapy, i.e. treatment with recombinant human erythropoetin was about 23% more cost effective than standard care.Thus, based on both clinical and economic grounds, recombinant human erythropoietin should be considered a preferred alternative to transfusion, especially in patients who are likely to experience chemotherapy/radiotherapy-induced anaemia and those at higher risk of transfusion-related complications.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveTo determinewhether influenza vaccination in the elderly is cost effective or cost saving compared with a non-intervention strategy andwhether it is worth framing a vaccination policy for this population.BackgroundInfluenza causes substantial morbidity and mortality in elderly people. Despite the availability of effective vaccines against this disease, vaccine coverage in the elderly is low in many countries. Evaluations of the economic impact of influenza vaccination can support public health policy decisions concerning vaccination and also may help influence changes in practice behaviour.MethodsWe performed a literature review of cost-benefit and cost-effectiveness evaluations of influenza vaccination in the elderly. We provide a summary of the principal findings from 11 economic evaluations of influenza immunisation and discuss their effect on policy decisions for vaccination in the elderly population.ResultsThe cost-benefit and cost-effectiveness results in elderly individuals, derived from 7 model-based simulations, 3 observational analyses and a case-control study, all support the recommendations for vaccination of all persons of 65 years and over that are currently endorsed in the US, Australia, New Zealand and many European countries. All evaluations showed that influenza immunisation was cost effective or would result in cost savings compared with a no-vaccination strategy.ConclusionsAlthough clinical and economic data indicate the benefit of influenza vaccination in the elderly, the vaccine coverage rate in many countries is disappointing, even when vaccine is provided free of charge. It is clear that strategies aimed at the patient or healthcare provider are needed to increase implementation of a vaccination policy to ensure that any recommended vaccine programme is clinically and economically effective.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveTo assess the utility of using a computer software program to determine whether epoetin alfa therapy drug use evaluation (DUE) criteria were met.Study designComputer software was designed to allow pharmacists to enter patient data such as haematocrit results and iron stores into a database. DUE data were collected upon entry into the study (through medical record review), at 6 months and at 12 months after enrollment for both the treatment and control groups (see Interventions section). The analyses of the 6- and 12-month DUE process and outcome criteria were conducted through an automated algorithm that was part of the software.The DUE evaluation was collected as part of a randomised, prospective, controlled study conducted at 32 sites across the US.InterventionsAt least 1 pharmacist at each study site completed a 4-day training session on end-stage renal disease and haemodialysis treatment, principles of anaemia management, use of an epoetin alfa software program, and review of specific DUE criteria. The treatment group consisted of patients managed by a trained pharmacist working in collaboration with a nephrologist being responsible for monitoring, evaluating and recommending epoetin alfa dosage regimens for patients. The control group consisted of patients for whom pharmacists monitored and collected haematocrit data but did not recommend therapy to the nephrologists.Main outcome measures and resultsThere were no statistically significant differences between patients in both the treatment and control groups with regard to the DUE results. However, the study demonstrated that computer databases can assist in determining whether specific DUE criteria have been met at multiple patient care sites. The computer software applied the same consistent methodology across a broad range of hospital practice sites and thus may have minimised investigator bias or site to site variations in criteria application.ConclusionsFuture DUE software algorithms should allow investigators/pharmacists to adjust important parameters such as the criterion threshold, time period of monitoring, ability to code ‘excused’ gaps in data and flexibility to modify criterion parameters.

ISSN:1173-8790    

出版商:ADIS    

年代:2000

数据来源: ADIS