ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Barrett’s esophagus is a condition that develops in approximately 10–15% of patients with chronic gastroesophageal reflux disease and is the only known major risk factor for esophageal adenocarcinoma. The incidence of esophageal adenocarcinoma has increased by 350% over the last 3 decades and the reasons for this dramatic increase are unclear. At the time of cancer diagnosis up to 50% of patients will have advanced regional or distant metastatic disease, with little or no chance of cure. The overall 5-year survival rate with advanced disease remains poor at <10%. Several studies have demonstrated an early stage of diagnosis and a marked improvement in the survival of patients with esophageal cancer detected by routine endoscopic surveillance in patients known to have pre-existing Barrett’s esophagus. The aim of endoscopic surveillance in patients with Barrett’s esophagus is the early diagnosis of esophageal cancer, when it is still potentially curable. The desired outcome is to further decrease the mortality rate associated with esophageal adenocarcinoma and identify and screen populations at risk for the development of dysplasia arising from Barrett’s esophagus. This is the principle of the current screening and surveillance guidelines set out by several societies, including the American College of Gastroenterology, the American Society of Gastrointestinal Endoscopy, and the European Society of Gastrointestinal Endoscopy. However, as most patients with Barrett’s esophagus do not develop adenocarcinoma, the cost effectiveness of endoscopic screening and surveillance strategies is questionable. To date, no prospective, randomized trials have been performed to evaluate the effectiveness of surveillance, the survival benefit in patients undergoing surveillance or the subsequent impact on healthcare costs. In this article, we focus on the basic principles and reasoning underlying the surveillance guidelines for Barrett’s esophagus. In particular, that the disease is clinically important and has a high prevalence; the transition to adenocarcinoma could have a high death and/or disability rate; early diagnosis of adenocarcinoma should reduce mortality; and the screening method should be easily applied, safe, relatively inexpensive, and applicable to a large number of patients. We then review arguments for and against screening and surveillance as they apply to these principles and discuss the current literature that reviews the effectiveness of such surveillance strategies, including an outline of cost analysis.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Thiazolidinediones (TZDs), including pioglitazone and rosiglitazone, have been prescribed for a number of years as monotherapy or combination therapy for glycemic control of type 2 diabetes mellitus. It has been hypothesized that the clinical advantages offered by TZDs compared with other commonly used oral hypoglycemic agents (OHAs) [i.e. improved glycemic control, improved lipid profiles, and low rates of hypoglycemic events] should lead to improvements in long-term outcomes, such as decreased incidence of micro- and macrovascular disease, leading in turn to improvements in life expectancy and quality-adjusted life expectancy. While the acquisition costs of TZDs are generally higher than other alternatives, such as metformin or sulfonylureas, it has been postulated that the higher initial acquisition costs of the medications should be offset by decreased costs of treating complications. As such, TZDs could represent an efficient form of treatment for type 2 diabetes.In order to provide an overview of studies performed to date, we have reviewed the available literature on the cost effectiveness of TZDs as a treatment in type 2 diabetes. An extensive literature search of major databases of indexed studies and proceedings of diabetes and health economics-related international conferences was performed to identify studies reporting health-economic outcomes for pioglitazone or rosiglitazone. Very few health-economics studies of TZDs have been published in peer-reviewed journals to date. A total of 16 studies (3 peer-reviewed international journal publications, 13 abstracts) were identified. These studies used various economic-simulation models to estimate the cost effectiveness of rosiglitazone or pioglitazone compared with other commonly prescribed OHAs, such as metformin, sulfonylureas, or acarbose, used either as monotherapy or in combination therapy for the treatment of type 2 diabetes. The studies demonstrated that the short-term clinical advantages of using TZDs translated into decreased incidence and progression of micro- and macrovascular complications, leading to improvements in life expectancy and quality-adjusted life expectancy. The short-term increase in costs due to the higher acquisition prices of the TZDs were partially offset by the long-term avoidance of complication costs. In Japan, pioglitazone was shown to lead to overall cost savings compared with other commonly used OHAs. While bearing in mind the issues of publication bias and other limitations outlined, the cost-effectiveness analyses identified and discussed in this paper lend support to the hypothesis that TZDs can be cost-effective therapies when compared with other commonly prescribed OHAs. Future clinical and health-economics studies must make direct head-to-head comparisons between pioglitazone and rosiglitazone to identify which TZD offers the best value for money. Furthermore, the more recently discovered renoprotective properties of TZDs must be factored into future analyses and are likely to have an important impact on their long-term cost effectiveness.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Patient adherence to a treatment plan is central to the control of coronary heart disease (CHD) and in the prevention of complications; it is reported to be the single most important challenge in the management of CHD and related conditions. The following article provides an overview of adherence in CHD, with particular emphasis on two important theories of behavior change: the ‘Health Belief Model’ and the ‘Transtheoretical Model’. Three types of individuals are discussed in relation to these theories:patients who are non-adherent (5–10% of the CHD population);patients who are partially adherent (30–40% of the CHD population); andpatients who are near-optimally adherent (50–60% of the CHD population).Adherence predictor strategies and recommended interventions for each of these groups are provided in table format. Disease management tools and resources that assist in targeting interventions to the unique adherence needs of these three very different groups are also listed. It was our conclusion that regardless of the interventions that are utilized in CHD management programs, understanding the differences between partially adherent, non-adherent, and near-optimally adherent patients, and targeting interventions to these groups, can optimize the impact of CHD interventions.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Current guidelines recommend the use of warfarin in all patients with atrial fibrillation (AF) and/or an artificial heart valve who are at high risk of thromboembolism. While anticoagulation with warfarin greatly reduces this risk, a careful system of monitoring and management is necessary to maintain a therapeutic dose and minimize adverse events. This rigorous process places a burden on providers, and many patients managed in typical office practices are not optimally anticoagulated.To improve the quality and efficiency of anticoagulation and remove its burden from office-based physicians, newer treatment models have evolved, including anticoagulation clinics and self-monitoring by patients at home. While these newer models often incorporate innovative programs to streamline warfarin management, little is known about their individual or relative economic merits or those of traditional office-based care. The routine costs of anticoagulation within any model have not been well documented. The cost of warfarin is readily available; however, attendant expenses, such as dose adjustment, laboratory testing, and medical encounters, are difficult to gauge. Because of these challenges in collecting practice data, most estimates of the cost of anticoagulation services have relied upon assumptions about practice patterns. Assessing the cost of anticoagulation is easier in a clinic setting because all costs relate exclusively to anticoagulation. A recent study of anticoagulation clinics estimated that annual direct costs per patient for anticoagulation services totaled approximately $US280–$US380 (2002 values). Bleeding and other complications experienced by anticoagulated patients add additional types of costs, with inpatient care accounting for more than one-half of the total cost of managing excessive anticoagulation. When quality of life is considered alongside costs to gauge the cost effectiveness of warfarin therapy versus aspirin (acetylsalicylic acid), warfarin appears to be cost-saving in patients at high stroke risk and cost effective in those at moderate risk. For patients at lower risk of stroke, aspirin is more cost effective than warfarin.With the aging of the population and consequent increases in patient groups requiring anticoagulation, the US healthcare system greatly needs improvements to anticoagulation management. New research must determine which models of management will provide the most favorable outcomes for high-risk patients at the lowest cost to payors and society.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Sickle cell disease (SCD), an inherited group of blood disorders, is a major public health problem worldwide. Patients experience severe anemia, increased risk of life-threatening infections, painful crisis, and chronic organ damage. Access to comprehensive care for SCD is known to improve outcomes; however, it is only reported from large urban centers serving one metropolitan area. Alabama, US, is a largely rural state with a significant number of children born each year with SCD. Prior to the development of our regional clinic network, the Children and Youth Sickle Network (CYSNSM), 50% of patients identified by newborn screening were not enrolled in comprehensive sickle cell care. The majority of non-enrolled patients lived in southern Alabama. Rural areas in this region are particularly plagued by poverty and poor access to healthcare. Life expectancy is equivalent to residents of Sri Lanka. This area has 15.7 doctors/10 000 residents compared with the statewide ratio of 41.9 doctors/10 000 residents.To improve access to care, a regional clinic network, the CYSNSM, was established in 1995. This paper reviews the impact of the CYSNSMon pediatric SCD in Alabama over the first 5 years of implementation.Since its inception in 1995, the CYSNSMhas provided care for 923 patients compared with 450 prior to the development of the clinic network. Currently, 90% of all cases identified by newborn screening are enrolled compared with 50% pre-CYSNSM. Prior to the network, the average age of patients at their first clinic visit was 21 months. In the post-CYSNSMperiod, the average age at first clinic visit decreased substantially to 5.3 months. Prior to the CYSNSM, patients traveled on average 90 miles to a comprehensive clinic. Post-CYSNSM, this distance has been cut in half to an average of 45 miles. A total of 70% of patients now live within 30 miles of a clinic. Most importantly, the infection death rate has decreased from 5.71 deaths/100 patient years to 1.94 deaths/100 patient years.The development, implementation, and evaluation of the CYSNSMshow that comprehensive care delivery in a rural setting is feasible and improves outcomes in pediatric SCD.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Gastroesophageal reflux disease (GERD) is one of the most common disorders of the gastrointestinal tract. Clinical presentation can vary from simple heartburn to erosive esophagitis. Some patients require long-term, possibly life-long, therapy. The cost of treatment is substantial, as patients with moderate to severe disease are high consumers of healthcare resources. The goal of therapy is to control symptoms, and to prevent complications, at a reasonable and manageable cost. Formulary decision making is more complex than simply choosing between proton pump inhibitors (PPIs) and histamine H2receptor antagonists (H2RAs); more importantly, it involves choosing the most cost-effective treatment strategy for a patient population. Since there are no long-term prospective economic studies available on the management of GERD, modeling studies provide the primary source of data for decision makers. A critical review of selected studies found that conclusions can vary based on a number of factors. These include the severity of GERD in the population being modeled, effectiveness endpoints, costs (drug and nondrug), and the inclusion of anti-reflux surgery. Effectiveness variables used in these models are generally based on randomized control trials in which endoscopic findings are used to judge success. This differs from the management of symptoms, as is common in clinical practice. In addition, the selection of which randomized clinical trial is used to define effectiveness endpoints can have a significant effect on the outcome. Thus, generalizability of economic studies often limits their value to decision makers. Pharmaceutical manufacturers have funded most of the studies in this area. For formulary decision makers to apply long-term economic analysis to their clinical practice, a critical review of these analyses is essential. Economic analysis can be a supplement to rational clinical judgment and experience in formulary decision making.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Currently, osteoporosis, defined as low bone mineral density (BMD), affects 30% of postmenopausal women and 8% of men >50 years old in Western society and these percentages are likely to increase as our elderly population expands. Osteoporosis-related fractures increase with age and reductions in BMD, with the greatest increase in hip, followed by vertebral, and then wrist fractures. Osteoporosis is associated with significant mortality and for each 1 SD decrease in BMD there is a 1.5-fold increase in mortality risk. Following a hip fracture, 25–30% of patients will die within 3–6 months and in some populations hip fractures account for 1.5% of all deaths. Osteoporosis and related fractures are associated with significant morbidity, with loss of independence, psychological effects, and an overall decreased quality of life.The current financial cost of osteoporosis in the US is $US14 billion and in the UK just over £1 billion, and these costs will increase 3- to 8-fold over the next 50 years. Treatments are available that have been shown to significantly increase BMD, decrease bone turnover, and as a result decrease fracture incidence. For reductions in both vertebral and fracture, the evidence is strongest for the use of the bisphosphonates alendronate and risedronate; while for vertebral fracture, effective treatments include raloxifene, etidronate, calcitonin, and calcium plus vitamin D. Recent data suggest that hormone replacement therapy (HRT) can prevent hip and vertebral fractures, but long-term use, or commencement in elderly women of some continuous combined preparations, is no longer recommended.It has been recognized that bone turnover and bone quality contribute to fracture risk and, therefore, biochemical assessment of bone resorption and formation may increase the clinical and cost effectiveness of treatment. Using a conservative estimate of fracture reduction (35%) over a 5-year period, an intervention costing $US500 (£333) per year is cost effective when targeted to women with osteoporosis who are ≥65 years of age. It has been calculated that the lower the intervention cost and the higher the effectiveness of treatment the lower the age at which the treatment would be cost effective. The increasing healthcare burden and effective treatments make osteoporosis an excellent candidate for disease management programs.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Background & ObjectiveIn France, non-homeopathic general practitioners (GPs) often use antibacterials to treat children with recurrent acute viral rhinopharyngitis; whereas homeopathic GPs tend to use homeopathic medicines. We compared the effectiveness, the quality of life of the parents, and the direct and indirect costs associated with treatment from homeopathic and non-homeopathic GPs.MethodWe assessed the direct (consultations, medicines, further tests) and indirect (time off work) costs of the two types of treatment to society, the patient, and social security. We also assessed the effectiveness of the treatment received and the quality of life of the parents.ResultsOf the 499 children included, 231 were treated by 62 non-homeopathic GPs and 268 by 73 homeopathic GPs. The effectiveness (assessed as complications/patient, total number of adverse events, and quality of life) [mean overall Parents of children with Ear, Nose, and Throat infections Quality of Life questionnaire©scale score] was better in the homeopathic GP group than in the non-homeopathic GP group. No significant difference was found between the two groups for the total costs to social security (euro98.55 for homeopathic GPs vs euro96.17 for non-homeopathic GPs). Homeopathic GPs initiated preventive treatment in 82.2% of their patients and used antibacterials in 20.9% of their patients, while non-homeopathic GPs initiated preventive treatment in 43.3% of patients and prescribed antibacterials for 89.6% of patients.ConclusionThis study produced new findings that indicate that, in France, acute rhinopharyngitis is handled differently by homeopathic GPs and non-homeopathic GPs: homeopathic GPs prescribe fewer antibacterials than non-homeopathic GPs for the treatment of recurrent acute rhinopharyngitis in children aged between 18 months and 4 years. Moreover, homeopathic treatment gave better results in terms of pragmatic medical effectiveness (fewer episodes and fewer complications) and the parents' quality of life, with similar total medical costs to social security. However, this study is potentially biased by the lack of homogeneity of the two patient-samples in terms of the ‘passive smoking’, ‘patient age’, ‘childcare’, and ‘type of occupation’ criteria because our study protocol did not provide for prior matching of the two patient-samples with respect to these criteria. The observations found in this study need to be confirmed by randomized clinical trials.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS