摘要:

A disconnection exists between our understanding of osteoporosis diagnosis/treatment and our ability to provide optimal bone healthcare in an organized fashion. This disconnection results, in part, from problems in inertia (moving forward with the attitude that osteoporosis is a disease worthy of management), direction (focusing on the ultimate goal of osteoporosis diagnosis and management, i.e. reduction in fracture), and flow (making it easy to do the right thing, i.e. taking the best available science, mixing it with expert opinion, and developing a program that allows all of the participants [physicians, allied healthcare providers, patients, insurers] to play a role).The Geisinger Osteoporosis Program, developed by the Geisinger Clinic of the Geisinger Health System in Danville, Pennsylvania, USA, combines elements of healthcare provider education, patient empowerment, and access to bone density testing and outcomes assessment to achieve the outcomes of fracture reduction in a cost-effective fashion.The healthcare provider education component includes guidelines that are data driven yet easy to navigate in an electronic milieu, combined with numerous educational opportunities. The patient empowerment component includes a ‘train the trainer’ process, whereby allied healthcare providers were taught to teach people in the community about improving their bone health and seeking osteoporosis testing where appropriate.The bone density testing component combines peripheral technology (heel ultrasound) with central gold-standard technology (dual energy x-ray absorptiometry [DXA] of the hip and spine) to provide access to technology for rural patients. A mobile DXA unit provides central DXA scanning at the convenience of the primary care physician’s office.Outcome measures from this program show increases in osteoporosis diagnosis, bone density testing, and prescription medication usage. A significant decrease in hip fracture was demonstrated, along with a reduction in costs based on a cost predictive model over a 5-year period.The Geisinger program has attempted to overcome some of the problems surrounding inertia, direction and flow in the management of osteoporosis by providing the following: clinical care pathways/guidelines that are simple, specific to patients and focus on care; consistent and integrative reports of bone density; getting primary care physicians engaged in the program; and making bone density testing as well as resources and expertise readily available. Using the Geisinger program as an example and applying it to the proper group of individuals, while having an investment in time and a commitment to improvement, physicians can help to move patients forward in maintaining healthy bones.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Alzheimer’s disease, which is a common disorder among the elderly, not only has devastating health consequences, but also poses a substantial economic burden. Three second-generation cholinesterase inhibitors – donepezil, galantamine and rivastigmine – represent the best available treatment for patients with mild-to-moderate stages of the disease. While these drugs have been effective in short-term clinical trials, it is necessary to understand the outcomes over the longer term in order to assess the appropriateness of these treatments.Data on the effectiveness of these drugs from information beyond the short-term clinical trials (e.g. long-term clinical trials and non-trial data) are now emerging. In most cases, the results indicate that, at least for some patients, continued treatment with cholinesterase inhibitors is effective in slowing cognitive decline. Whether these results translate to clinically and economically relevant outcomes is less clear. The AD2000 trial in particular, a 1-year, placebo-controlled trial, seems to suggest that cognitive benefits, even if maintained over the mid-to-long term, may not adequately reflect overall deterioration in patients. Naturalistic studies, as well as analyses of administrative data, however, mostly suggest that these benefits are real and relevant.The cost effectiveness of treatment has been evaluated primarily through modeling. These studies have shown that the costs of treatment can be offset by savings in other areas as a result of slowed disease progression. When all medical costs are considered, relatively small delays in disease progression are required to offset treatment costs, but a large portion of these offsetting savings are a result of delayed institutionalization. To payors not responsible for institutional care costs, these predicted economic advantages are less relevant. While data are limited, some research indicates that reductions in other costs may be sufficiently large to fully offset the costs of treatment.Economic comparisons among active treatments have only been made in one study so far. Based on meta-analyses of trial data and a model estimating disease progression, that study concluded that galantamine provided the best health and economic projections. Head-to-head studies, however, are limited and provide conflicting results.While the treatment of patients with Alzheimer’s disease using cholinesterase inhibitors will likely continue to increase, there is no definitive answer regarding the appropriateness of long-term treatment. A reasonably complete answer will likely not be available until more long-term data from actual practice become available.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Disease management has emerged as an important tool to increase quality of care, improve patient outcomes and control costs. Reducing provider practice variation is a key aspect of successful disease management. Clinical practice guidelines are a useful tool to reduce practice variation but are often underutilized. Provider training interventions, particularly using multiple educational strategies, have been proven to be effective in increasing guideline adherence. For maximal effect, provider training must also be combined with system interventions to support and sustain new provider behaviors.Educational technologies encompass electronic-based delivery methods and innovations in instructional design such as adult education, problem-based learning, and competency-based training. Innovations in educational technology are lowering common barriers to provider training such as limited provider time, less provider acceptance of traditional classroom methods and limited organizational training resources. Electronic technologies are central to delivery of distance learning, which uses technology to link instructors separated from learners by time and /or distance. Distance learning includes synchronous methods (which link learners who are separated by geographic distance but allow for simultaneous interaction) and asynchronous methods (which allow for interaction at different times). The range of electronic technologies include relatively simple and inexpensive methods requiring minimal infrastructure such as audio or videotape instruction, to technology-intensive methods such as videoconferencing or telemedicine, involving substantial infrastructure. Computer-assisted learning methods range from simple freestanding programs, to more sophisticated interactive Internet-based instruction, to highly sophisticated and realistic patient simulators.Constraints to implementing innovative educational technologies include providers’ discomfort with electronic technology, increased time and cost of instructor-intensive face-to-face instructional methods and the requirement for extensive infrastructure and technical support of some electronic-based technologies. Selecting appropriate educational technology for disease management provider training requires careful consideration of both program and provider characteristics. More research is needed on the comparative effectiveness, synergies, limitations and health economics of innovative educational technologies in provider training.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Cigarette smoking and other tobacco use impose a huge and growing public health burden globally. Currently, approximately 4 million persons are killed annually by tobacco use; by 2030, estimates based on current trends indicate that this number will increase to 10 million, with 70% of deaths occurring in low- and middle-income countries. Numerous studies from high-income countries, and a growing number from low- and middle-income countries, provide strong evidence that increases in tobacco tax, dissemination of information about health risks from smoking, restrictions on smoking in public places and in workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies are all effective in reducing tobacco use and its consequences. Despite this evidence, tobacco control policies have been unevenly applied, partly because of political constraints.When the tobacco control policies that have been adopted by individual governments were reviewed, upper-middle-income countries had significantly higher total legislative scores than low- and middle-income countries. This suggests a relationship between the comprehensiveness of tobacco control policies and income level. However, there are other factors that may contribute.A key political tool for addressing political opposition to tobacco control policies is an earmarked tobacco tax. In addition, a key pillar to help overcome some of the constraints against implementing effective tobacco control policies is the Framework Convention on Tobacco Control (FCTC). The FCTC aims to be an international treaty that would commit countries to adopting strong, effective tobacco control policies. The treaty was recently unanimously adopted by the 192 member states of the WHO.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

AimTo determine the effectiveness of a multi-component managed-care intervention in reducing inappropriate antibacterial prescribing for viral respiratory infections (VRIs).Study designAn episode-based retrospective analysis of administrative claims data between 1998, the year prior to the initiation of the first component of the intervention, and 2001, the year after full implementation.Patient group studiedAll health plan members of the Hawaii Medical Service Association (Blue Cross Blue Shield Hawaii) in the US who sought care for an upper respiratory infection.MethodsTo ensure that changes in the rate of antibacterial prescriptions were not because of viral-related infections being coded as bacterial, we measured, in parallel, diagnoses of similar bacterial respiratory infections. Persons with chronic bronchitis, emphysema, and asthma were excluded. Episodes temporally associated with any diagnosis for a non-respiratory bacterial infection were also excluded.Main outcomesThe main study outcome was change in VRI-associated antibacterial utilization. Secondary outcomes included episode-related outpatient, emergency department and inpatient utilization, and estimated cost savings related to changes in antibacterial prescribing rates.ResultsThe population-based rate of antibacterial use for VRIs decreased significantly between 1998 and 2001, from 39.9% to 33.5%. There was no observed increase in the proportion of bacterial to viral episodes over the same period of time, suggesting that the observed decrease in rates was not a result of coding changes. This reduction in antibacterial prescribing for VRIs was not associated with an increase in emergency department or inpatient utilization. A reduction in VRI-related outpatient visits was observed. The reduction in inappropriate antibacterial prescriptions was estimated to result in a cost saving of approximately $US500 000 over the 4-year study period, assuming the antibacterials prescribed were similar over time (1998 values). The majority of savings were found in the last year, after full implementation of the intervention.ConclusionsWhile this study did not offer evidence that one component of the intervention was effective by itself, the combination of all components was associated with decreased antibacterial prescribing for VRIs. The observed reduction in antibacterial prescribing for viral episodes was not associated with increased healthcare visit utilization, and is estimated to be associated with a sizable cost saving. While further research is recommended, this study offers preliminary evidence that multi-component physician feedback programs may be effective in reducing the inappropriate prescribing of antibacterials, and managed care organizations can use claims-based, episode-defined analyses to evaluate the effectiveness of their initiatives.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Postmenopausal osteoporosis is a very common disease, and approximately half of all women aged >50 years will experience an osteoporotic fracture during the remainder of their lifetime. The predominant cause of postmenopausal osteoporosis is the decline in estrogen levels, which causes an increase in bone turnover, and results in a loss of bone mass throughout the entire skeleton. Fragility fractures, either vertebral or nonvertebral, have a considerable adverse effect on quality of life in women with osteoporosis and place a significant burden on society in terms of healthcare costs.Management of postmenopausal osteoporosis includes alteration of modifiable risk factors (e.g. lifestyle and propensity to fall), ensuring adequate calcium and vitamin D intake, and pharmacological treatment to decrease fracture risk by slowing or preventing bone loss and preserving bone strength. Raloxifene (Evista®), a selective estrogen receptor modulator that partially mimics the effects of estrogen on bone and lipid metabolism and acts as an antiestrogen in the breast and endometrium, is indicated for the prevention and treatment of postmenopausal osteoporosis. Raloxifene increases bone mineral density at vertebral and nonvertebral sites, and decreases the risk of vertebral fracture to a similar extent to the bisphosphonates alendronate and risedronate. However, effects on nonvertebral fracture risk, including the risk of hip fracture, have not been observed.Raloxifene appears to reduce breast cancer risk (in women at average risk) and cardiovascular risk (in women at increased risk) without stimulating the endometrium, and does not cause vaginal bleeding or breast pain. However, the drug causes hot flashes in some women, and increases the risk of venous thromboembolic events by about the same amount as hormone replacement therapy (HRT).In economic models, raloxifene is cost effective compared with no treatment, HRT, calcitonin, or alendronate for the prevention or treatment of postmenopausal osteoporosis.In conclusion, raloxifene is a valuable and cost-effective therapy for preventing the progression of osteoporosis and for reducing vertebral fracture risk in osteoporotic postmenopausal women. The tendency for raloxifene to cause hot flashes, and its apparent lack of effect on hip fracture risk, may preclude its use in women with vasomotor symptoms and in patients at high risk for hip fracture. Results from large ongoing trials are needed to confirm the effects of raloxifene on breast cancer and cardiovascular disease. However, the effects of raloxifene on breast cancer and cardiovascular risk without stimulating the endometrium make the drug an attractive therapy for the prevention and treatment of postmenopausal osteoporosis.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS