摘要:

Managed care, with its restrictions on patient and provider autonomy, has dominated the delivery of healthcare in the US over the last decade. The latest model of managed care has focused on disease management programs, which outline optimal cost-effective processes for care, built on evidence-based guidelines. Patients and providers seem to be more accepting of these programs than of the restrictive managed care practices, but ethical dilemmas remain for both patients and providers when participating in such programs. The basic ethical tenets of beneficence (to do good), autonomy (to make one's own decisions) and non-maleficence (to do no harm), have been well accepted by the medical community. Under managed care these basic tenets have been challenged, with a notable impact on the principle of autonomy; patients lose their choices in selecting care providers, while healthcare providers face restrictions on what pharmaceutical agents they can prescribe and how to care for patients.Additionally, the changing nature of managing care has highlighted conflicts of interest between: patients and the providers of healthcare; patients and the implementers of health plans; and providers and health plans. Conflicts of interest between various parties involved in healthcare challenge the fundamentals of ethical principles, particularly autonomy and beneficence.Recently, there has been greater recognition of the ethical notion of social justice (including the competing concepts of distributive and contributive justice), in terms of the provision of healthcare, partly due to the development of concerns over the expense of, and access to, healthcare. Distributive justice reflects the broader societal concerns over the provision of scarce resources for all citizens, and argues for universal coverage schemes. The concept of contributive justice recognizes that principles of equity demand that we allocate commonly collective funds fairly to those who have contributed to the pool of funds; in the realm of healthcare in the US this is particularly relevant for those who have insurance coverage.Disease management programs offer great potential to improve healthcare. Programs that are developed with attention paid to the principles of beneficence and social justice as well as to concerns regarding patient and provider autonomy can limit conflicts of self-interest.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

The methods used to collect information on patient-reported outcomes (PROs) can affect the validity, reliability and sensitivity of the data. This review examines the influence of a variety of methodological issues that occur. In particular, when patients are asked to rely on their memory to aggregate and summarize their experience, a variety of inaccuracies and biases can affect the data. As the extent and magnitude of recall bias have become more well-known, researchers have increasingly turned toward collecting data in the field, closer in time to events and experiences of interest. Diary methods require patients to self-monitor their experiences, disease episodes and healthcare utilization over time. The collection of diary data from patients places a premium on adherence to the data collection protocol. Recent evidence suggests that patients routinely fail to adhere to diary protocols, thus introducing retrospective error and biases into the data. Reasons for patients' non-adherence to data collection protocols include their desire to appear to be ‘good’ patients which can result in back-filling PRO entries before a site visit, simply forgetting, and data collection methods that fail to help patients be adherent to the data collection protocol. Principles that can be used to enhance patient adherence to PRO data collection methods include good patient training, creating simple and intuitive user interfaces for PRO assessments, and actively driving the protocol by helping patients remember to complete PRO measures as required by the protocol.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Multidisciplinary team disease management has evolved into consensus ‘best practice’ in the care of patients with chronic heart failure (CHF). The mission of disease management for patients with CHF is to shift care from the hospital to the clinic and to the home, optimize quality of care in concert with consensus guidelines, reduce admissions by 40% and improve functional status and quality of life. The Partners Heart Care program has been operational for 5 years and enrolled hundreds of patients throughout the Partners Health Care System in Boston, Massachusetts, USA. This program enrolls patients following hospital discharge in a physician-directed multidisciplinary interventional care program, run by nurse practitioners, which incorporates several levels of care dependent upon patient acuity. Following clinical stabilization and optimal titration of oral therapy in concert with consensus care guidelines, patients transition to a longitudinal care program. The primary responsibility for the clinical care of patients in all phases of the program resides with nurse practitioners and primary care physicians, with heart failure specialists serving as consultants on an as-needed basis. Data on pre-specified program outcomes such as quality of care, mortality, hospital admissions, functional status, procedure use and costs are collected prospectively and provide benchmarks for continuous quality improvement. The most critical lesson learned in development to date is the necessity of precise tailoring of the program to local patient and provider needs with local oversight and management.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

This article evaluates the cost effectiveness of and patients' willingness to pay for interventions by community pharmacists in the overall context of pharmaceutical care. The rationale for interventions by pharmacists in patient care is examined from the viewpoint of clinical and economic needs of the healthcare system. The philosophy of the practice of pharmaceutical care is compared with that of disease management. The analysis shows that both clinical and economic deficiencies exist in the current healthcare system that the practice of pharmaceutical care could help to rectify. More importantly, there is congruence in the practice philosophies between pharmaceutical care and disease management, with both being patient centered and outcome focused. Therefore, the practice of pharmaceutical care can be facilitated within the context of disease management.There are many examples showing that interventions by community pharmacists can result in cost savings. However, there are few studies on consumers' willingness to pay for such services provided; those to date suggest that consumers are willing to pay a modest amount for pharmaceutical care provided by community pharmacists.Barriers for implementing pharmaceutical care by community pharmacists are discussed, and some suggestions of strategies to be adopted for the successful implementation of pharmaceutical care are made. The author is of the view that before full reimbursement for pharmaceutical care is achieved, the successful implementation of pharmaceutical care by community pharmacists will hinge on better utilization of available resources and improvement in communications between pharmacists, patients and other healthcare professionals. Coordinated and systematic efforts would be required to collect information regarding consumers' willingness to pay in order to assist in negotiating an acceptable level of reimbursement.Finally, in this age of accountability in healthcare, it is necessary for community pharmacists to demonstrate the benefits of their interventions in terms of better outcomes whether they be clinical, economic and humanistic, and that the improvement is achieved at a cost acceptable to the healthcare system. Without the evidence of acceptable cost effectiveness and perceived benefits, any attempt to promote the implementation of pharmaceutical care by community pharmacists, especially in countries where the concept is relatively new, would only be perceived as lobbying for the interest of a particular professional group, and could not be justifiable.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

IntroductionProvisions in the Balanced Budget Act of 1997 directed the US Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) to begin focusing attention on the standardized measurement of health outcomes of Medicare beneficiaries as well as testing the effectiveness of various disease management interventions at improving these outcomes.The CMS, in collaboration with the US National Committee for Quality Assurance, developed the Medicare Health Outcomes Survey (HOS) as the first health outcomes measure from the patient's perspective in Medicare managed care. This new source of data, using the Medical Outcomes Study Short Form 36-Item Health survey (SF-36®) as its core measure, provides valuable standardized health outcomes information about Medicare managed care enrollees in general and the chronically ill in particular.Study designFrom May through July 1998, a longitudinal, self-administered survey which utilized the SF-36®(a health status measure which assesses both physical and mental functioning) was administered to 1000 randomly sampled Medicare beneficiaries who were continuously enrolled for a 6-month period in a Medicare managed care health plan. This cohort was re-surveyed from April though June of 2000. We analyzed data from the cohort I baseline and re-measurement analytic sample of 51 700 individuals.ResultsUsing the change in SF-36®physical component summary scores and mental component summary scores over a 2-year period, we demonstrated that the presence of chronic disease has a negative impact on both the physical and mental health functioning of Medicare managed care enrollees over time. With few exceptions, the negative effect of chronic disease on physical and mental health is found to be independent of gender, race, and socioeconomic status as measured by level of educational attainment. Differences in mean health status scores across levels of chronic conditions suggest that preventing the onset of disease is best for maintaining optimal health.ConclusionsDisease management interventions which are properly designed and implemented have been shown to measurably improve patient outcomes by providing high quality, cost-effective care. Recognizing the need for standardized outcome measures and scientifically validated disease management interventions, the CMS has taken a leadership role by developing and implementing the Medicare HOS and disease management demonstration projects.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Galantamine is one of several orally administered cholinesterase inhibitors that improve cognition in patients with mild to moderate Alzheimer’s disease. Compared with placebo, galantamine 16 or 24 mg/day improved cognition and activities of daily living, delayed emergence of behavioral symptoms and reduced caregiver burden in three pivotal randomized studies of 5 or 6 months’ duration.Galantamine may reduce the considerable economic burden of Alzheimer’s disease by delaying the need for full-time care (FTC) in patients with mild to moderate Alzheimer’s disease. In pharmacoeconomic analyses with a time horizon of 10 years conducted in Canada, Sweden, The Netherlands and the US, data from the pivotal trials were incorporated into a model to examine economic implications associated with galantamine treatment. FTC was defined in the model as the consistent requirement for caregiving and supervision for the greater part of each day regardless of the location of care and the identity of caregiver. When the effect of galantamine 16 or 24 mg/day was analysed from the perspective of a comprehensive healthcare payor, treatment was associated with cost savings (inclusive of drug costs) relative to no treatment, regardless of country for which the model was customized. Cost savings resulted from the delay in the time until FTC was required in patients with mild to moderate disease. In sensitivity analyses, cost savings were most sensitive to the cost of institutional care.In the analyses that considered the effect of galantamine 24 mg/day solely on cognition, galantamine was predicted to reduce the time FTC was required by ≈10% in patients with mild to moderate Alzheimer’s disease compared with no pharmacological treatment. Greater reductions in the time that FTC was required were predicted when the effects of galantamine 16 or 24 mg/day on behavioral symptoms in addition to cognition were considered in the US analysis or in sensitivity analyses in studies in other countries.In conclusion, pharmacoeconomic analyses, which were based on modelling of data from pivotal clinical trials with galantamine and included drug costs, indicate that galantamine treatment may result in cost savings from a healthcare payor perspective. The effects of galantamine on cognition and behavioral symptoms in patients with mild to moderate Alzheimer’s disease are predicted to delay the need for FTC, which may result in cost savings. From a societal perspective, the caregiver burden of caring for a patient with Alzheimer’s disease in the community may be decreased and the time that patients have without severe disease may be prolonged.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS