摘要:

Clinical practice relies on structured learning that is applied to a patient care setting. Patients present with symptoms and providers try to fit these complaints into known disease categories. Providers depend on memorized algorithms to direct diagnosis and treatment. Well thought-out guidelines developed by professional societies and based on the best available evidence have become the standard in modern medical care. Guidelines are developed to assist practitioners in making appropriate healthcare decisions, to help standardize medical care and improve quality. Guidelines attempt to change practice behavior towards an established norm when evidence is available or toward a consensus opinion when randomized trials are lacking. Patients seeking medical care expect that their practitioner is providing up-to-date, quality medical care. The payors of this care are also interested in quality but must pay attention to medical costs. Both the patient and the payor are invested in providers who use the best available evidence in providing care that is clearly based on guideline development and dissemination.The American Pain Society (APS) has written three practice guidelines, the most recent of which is theGuideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis, published in 2002. Based on high quality research, when available, and consensus opinion from opinion leaders, these guidelines are endorsed throughout the world’s medical community. Like any other guidelines, the goal is to standardize care and improve quality.The future will bring more development of guidelines like those from the APS. As studies improve and trials show more effective treatment paradigms, well researched, appropriately designed guidelines will emerge which are structured for busy practices. But this will not be enough; providers need to be made aware of the guidelines, educated on their use, shown appropriate studies documenting efficacy, given simple strategies to implement these guidelines, repeatedly reminded of the appropriate care and, finally, monitored for compliance. For guidelines to be effective they must be tested, disseminated, and their impact on healthcare outcomes must be assessed.Payors want evidence of the value for their expenditures and guidance by professional societies in allocating limited resources. At the same time, payors are struggling with quality issues. Guidelines can help standardize care that may also be more cost effective as well as satisfy quality concerns from regulatory agencies and the public. Understanding where guidelines make an impact and why resistance develops to well meaning, expert based documents will help us in our disease management efforts.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Three-tier pharmacy benefit plans are the dominant structure in prescription drug coverage today. In these plans three copayments exist. The lowest copayment is for generics, the middle copayment is for preferred brands and the highest copayment is for non-preferred brands. The premise of these plans is that by shifting the burden of cost onto the consumer, consumers will be more judicious in their prescription purchasing behavior. This review article outlines the empirical evidence regarding the utility of three-tier plans in changing consumer’s prescription purchasing behavior.The results from a few key studies appear to suggest that three-tier plans reduce prescription drug spending for health plans while significantly increasing the cost-sharing amount for consumers. While the increased cost sharing created higher levels of dissatisfaction among three-tier plan members, it appears that they modify their behavior in accordance with these plans by switching to lower cost formulary alternatives. The factors that appeared to affect these behaviors included provider opinion and the comparability of the formulary and non-formulary alternatives. However, there are a myriad of factors that could influence the decision to switch from one drug to another (one example is switching for purely clinical reasons), and thus a clear link between the implementation of three-tier plans and switching behavior is hard to establish.What still remains unanswered is the impact of three-tier plans on vulnerable populations such as the elderly, low-income individuals and individuals with chronic disease who may be most adversely affected by the implementation of such policies. These individuals may discontinue or reduce appropriate utilization of their medications that could lead to adverse outcomes. Adequate follow-up for these vulnerable populations who are enrolled in a three-tier plan needs to be conducted to ensure appropriate medication use.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Background and objectiveIn day-to-day practice, asthma treatment and self-management often fall short of the objectives defined by clinical practice guidelines. The objective of this study was to determine whether a population-based asthma disease management program, using broad-based educational interventions, can have a favorable impact on physician and patient adherence to guidelines-based care.MethodsA longitudinal, before-and-after design was used to evaluate program impacts on pharmacotherapy and health status. Patients with asthma (n = 35 450) were enrolled in the program from September 2000 through to June 2001. Patients were identified for the study based on a 12-month retrospective analysis of pharmacy claims. Patients were members of prescription benefit plans managed by Medco Health and were aged 5 years and older. Patients in the intervention group received asthma education materials during the 12-month period following enrollment. The materials emphasized guidelines-based principles of asthma pharmacotherapy, self-management, trigger avoidance and patient-physician partnership. Physicians received guidelines-based flow sheets to facilitate therapy tracking, and pharmacotherapy review. Asthma drug utilization was measured during the 12-month period prior to enrollment and the 12-month period following enrollment. Utilization data on controller and reliever medications were derived from a pharmacy claims database. Drug utilization changes for the intervention group were compared with those for matched controls. A health survey was conducted on a random sample of program participants at enrollment and at 12-month follow-up. The health survey included questions on asthma-related quality of life (QOL), medical utilization, productivity, and self-management skills.Main outcome measures and resultsThe percentage of patients who started controller therapy during the study period was significantly higher for the intervention group than the control group (20.7% versus 18.1%, p < 0.001). The controller prescription fill rate increased significantly in the intervention group compared with controls (p < 0.0001); the increase was primarily driven by increased refill rates for patients already using controllers. Reliever prescription fill rates decreased for both the intervention group and controls. Program participants reported significant improvements in asthma-related QOL (p < 0.05) and self-management skills. Self-reported medical utilization decreased for office visits (p < 0.05) and emergency room visits (p < 0.01).ConclusionsA population-based asthma disease management program can improve controller prescribing rates (new therapy starts), controller adherence rates (refill persistency), and self-management skills. These changes in physician and patient behavior help close the gaps between guidelines and practice in asthma therapy.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Genital herpes simplex virus (HSV) infection has substantial economic and quality-of-life consequences; not least is the risk of transmission to the fetus/infant during parturition with the subsequent effects on the family, society as a whole and healthcare providers. While general screening programs for HSV infection are not cost effective, screening of susceptible subgroups may be acceptable in some circumstances (e.g. immunocompromised patients, presumed discordant heterosexual couples, pregnant women) despite the high costs involved. First-line options for treatment and suppression of genital herpes in Europe and the US include valaciclovir, aciclovir and famciclovir. The established efficacy of valaciclovir, along with its potential for once-daily administration in many patients (versus administration up to five times daily for aciclovir), its positive effect on quality of life, its suppressive efficacy in late pregnancy and its proven reduction of viral transmission between heterosexual discordant partners support the drug's position as a first-line therapy and suppression option in patients with genital herpes. However, the high acquisition costs compared with aciclovir will affect formulary decisions in some patients, and the favored niche for this drug, at least until evidence of prevention of transmission is demonstrated for other antivirals, would seem to be in the prevention of transmission in susceptible subgroups such as couples discordant for HSV infection (especially male-positive/female-negative couples who are planning a pregnancy), and the treatment and suppression of genital herpes in patients particularly receptive to once-daily administration.Potential disease management programs for genital herpes would thus need to balance the high costs of HSV screening and the relatively high acquisition costs of valaciclovir against the convenience of once-daily administration, the improved quality of life and the proven potential for reduced viral transmission to susceptible partners (with potential for downstream reductions in the overall socioeconomic burden of the disease) associated with oral valaciclovir.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Overactive bladder (OAB), a common condition affecting ≊16–17% of adult men and women in Europe and the US, is characterized by symptoms of urinary urgency, with or without urge urinary incontinence (UUI), usually with micturition frequency and nocturia. OAB is thought to result from abnormal, involuntary detrusor contractions during bladder filling. The symptoms of OAB have a considerable adverse effect on quality of life (QOL) in affected patients, and are associated with an increased risk of comorbidities, and increased direct and indirect costs.Management of OAB focuses on symptom improvement, and includes nonpharmacologic and pharmacologic therapy. Extended-release tolterodine (Detrusitol®XL, Detrol LA®, Detrusitol SR®, Detrusitol®Neo, Detrusitol®Retard, Unidet™) is an oral, once-daily, nonselective, competitive antimuscarinic drug. It acts on smooth muscle motor efferent pathways, including bladder detrusor muscle, and is a first-line therapy for OAB. Extended-release tolterodine is at least as effective as immediate-release tolterodine in improving UUI and other symptoms associated with OAB (including urinary frequency, urgency symptoms, voided volume/micturition), and in improving health-related QOL. It has similar efficacy to oral immediate- or extended-release oxybutynin, or transdermal oxybutynin.The likelihood of dry mouth, the most bothersome anticholinergic adverse effect associated with antimuscarinic drugs, is significantly reduced with extended-release tolterodine in patients with OAB compared with immediate-release tolterodine. Dry mouth also occurs significantly less frequently with extended-release tolterodine than with immediate- or extended-release oxybutynin. The incidence of dry mouth with extended-release tolterodine or transdermal oxybutynin is similar.In economic models, extended-release tolterodine is more cost effective in patients with OAB than no treatment, or treatment with immediate-release tolterodine or immediate-release oxybutynin, and is as cost effective as extended-release oxybutynin.In conclusion, clinical and economic data support the use of extended-release tolterodine as a first-line therapy in the management of adult patients with OAB. It is at least as effective as immediate-release tolterodine, but is associated with a lower incidence of dry mouth. Moreover, the convenient once-daily administration regimen offers the potential for good compliance. The favorable efficacy and tolerability profile of extended-release tolterodine has been demonstrated for up to 12 months. Extended-release tolterodine is as effective as oral immediate- or extended-release oxybutynin, but is better tolerated in terms of dry mouth. It has similar efficacy and tolerability (including dry mouth) to transdermal oxybutynin. Extended-release tolterodine is, therefore, a valuable first-line therapy in the treatment of OAB.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS