摘要:

Issues related to avoidable mortality in people with epilepsy have been highlighted in the National Sentinel Clinical Audit of Epilepsy-Related Death in the UK. This audit concluded that 39% of adult epilepsy-related deaths and 59% of epilepsy-related deaths in children were potentially or probably avoidable. Particular attention was drawn to the important and poorly understood condition of sudden unexplained death in epilepsy. This audit prompted a report by the Chief Medical Officer, which was followed by a document prepared by the Department of Health (England) entitledImproving Services for People with Epilepsy: Department of Health Action Plan in Response to the National Clinical Audit of Epilepsy-Related Deaths. The action plan comprises the following sections:Introduction;Pathology and Post Mortem Investigations;Improving Care Management and Treatment of Epilepsy; andInformation Provision.The fact that the Department of Health in England has drawn attention to these important matters is in itself worthwhile. However, the action plan does not give a firm commitment to taking the necessary steps required to rectify the shortcomings in the current services.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Managed care presents interesting opportunities to optimize clinical and economic outcomes related to drug prescribing. There are very few randomized controlled trials that have evaluated methods to educate or incentivize physicians, implement formulary management or guideline tools, profile physicians, and implement pharmacist interventions to ensure optimal drug prescribing. Single methods of optimizing medication outcomes have not been shown to be as effective as multifaceted approaches. Specific reinforcement of the message at the time of prescribing has been shown to improve antibiotic prescribing in patients with chronic bronchitis and improve adherence to treatment guidelines for the management of patients following myocardial infarction. Results from a randomized controlled trial showed that changes in pharmacy benefit design decreased costs and medication utilization. Much of the literature evaluating the effectiveness of utilization management techniques in optimizing drug therapy outcomes is retrospective in nature. However, pharmacist intervention has been shown to reduce polypharmacy in a randomized controlled trial in the elderly. Appropriate prescribing scores were improved and this improvement was sustained at 12 months post intervention.Clinical pharmacy services have been shown to reduce hospital admission and hospital days, decrease prescription and total health care costs, reduce the number of drugs per patient, and improve attainment of target low density lipoprotein cholesterol values.Recent analyses have shown that there is a higher likelihood of achieving improved outcomes of care when three or more of the following aspects of healthcare are impacted: patient self-management, clinical information availability, redesign of the way care is delivered, decision support strategies, the healthcare system, and the provider organization. In a review of interventions designed to improve the care of patients with chronic illnesses, process variables were improved when one or two of the aspects were improved. Outcome variables were improved when three or four of the aspects were impacted.There continues to be great focus on improving the quality of care in managed care environments. With the passing of the Medicare legislation in the US, by 2006 the vast majority of citizens will receive healthcare in managed care environments. Additional research designed to explore methods of optimizing drug therapy outcomes is needed to characterize the most efficient, transparent, and least costly ways to reduce misuse, overuse, and underuse of prescription drugs.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

The poor efficacy and tolerability of conventional antipsychotic treatment in schizophrenia, together with discovery of the ‘atypical’ antipsychotic clozapine, led to the development of several other atypical antipsychotic drugs. Those now available manifest clinically relevant differences in symptom efficacy and adverse effects, and most evidence supports their superior efficacy and tolerability compared with conventional treatment. Alongside these novel drugs have arrived concerns regarding new adverse effects, instead of the extrapyramidal phenomena which were one of the main drawbacks of conventional antipsychotics. These adverse effects comprise weight gain, diabetes mellitus and QTc interval prolongation. Overall, however, there is no evidence that atypical antipsychotics are more problematic than conventional antipsychotics, as there are marked differences between individual drugs in both classes. Current guidelines recommend the use of atypical antipsychotics as first-line treatments in a wide range of patients with schizophrenia, despite significant caveats regarding the quality of evidence to support use of these drugs in general. Advantages claimed over conventional antipsychotics are greater cost effectiveness, superior relapse prevention and possible benefits regarding quality of life and the natural course of schizophrenia. These advantages, if valid, will benefit stakeholders, whether they are consumers or providers of mental healthcare. However, major discrepancies remain between guidelines for first-line use and current practice. Poor take-up of atypical treatment and off-license use of both conventional and atypical drugs, particularly in primary care, are substantial problems that remain unaddressed. If guidance on first-line atypical therapy for schizophrenia is to be followed, processes such as audit must be applied widely to facilitate implementation of best-practice guidelines. Only then will the supposed benefits of first-line use be verified, or otherwise.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

ObjectiveTo assess the relationship between diabetic medication adherence, total healthcare costs, and utilization within patients with type 2 diabetes mellitus and concomitant diabetes and cardiovascular disease (CVD).Research design and methodsThis study was a retrospective analysis of pharmacy and medical claims from 1 April 1998 through 31 March 2000 within a managed care organization’s database. Patients were identified who had received an oral antihyperglycemic medication or had a diagnosis of CVD, were continuously enrolled in the health plan, and were ≥30 years of age. The likelihood of an emergency room (ER) or hospital admission and total healthcare costs related to all causes, stratified by antihyperglycemic medication adherence cohort within the diabetes only and diabetes + CVD groups, were examined over 360 days from the date the patient was identified.ResultsFor diabetes patients with ≤75, >75 to ≤95, and >95% adherence, adjusted total healthcare costs (from April 1998 to March 2000) were $US5706, $US5314, and $US4835, respectively (p < 0.001). Patients with ≤75 and >75 to ≤95% adherence had a 31% and 19% greater chance of a hospital/ER admission than those in the >95% cohort, respectively. Adjusted healthcare costs (from April 1998 to March 2000) for those with ≤75, >75 to ≤95, and >95% adherence within the diabetes + CVD cohort was $US37 648, $US31 547, and $US25 354 (p < 0.001). Patients who were ≤75 and >75 to ≤95% adherent had a 44% and 51% greater chance of a hospital/ER admission than those with >95% adherence, respectively.ConclusionsHigher adherence to oral antihyperglycemic agents is associated with lower healthcare resource utilization and costs for patients with diabetes only and patients with concomitant diabetes and CVD.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

ObjectiveTo characterize the dose administration patterns of tumor necrosis factor (TNF) inhibitors for the treatment of rheumatoid arthritis (RA) within a managed care organization (MCO).MethodsPatients with RA who received either infliximab or etanercept between 1 January 2001 and 31 May 2002 were identified using MCO pharmacy and medical claims. Prescribers were asked to send copies of the identified patients’ charts. TNF inhibitor dose administration information was abstracted from the charts.Results1869 patients were potentially eligible and 936 of these could be linked to prescribers. A total of 457 of 936 (49%) requested charts were obtained. Of the 369 eligible patients, 164 received infliximab (44%) and 205 received etanercept (56%). The mean first doses ordered of infliximab and etanercept were 3.5 ± 0.6 mg/kg and 27.9 ± 24.2mg, respectively. Subsequent doses ordered were 4.2 ± 1.4 mg/kg and 25.7 ± 13.9mg, respectively. Overall, 67% of infliximab infusions used less than or equal to the expected number of vials if administered at 3 mg/kg. The estimated mean annual medication cost per patient (2004 values) was determined to be $US13 936–$US 15 734 for infliximab and $US17 105 for etanercept; however, these costs do not consider the need for methotrexate administration with infliximab and costs associated with the route of administration (intravenous for infliximab and subcutaneous for etanercept).ConclusionThe majority of TNF inhibitor doses were within recommended ranges. Although infliximab can be administered at doses up to 10 mg/kg, the majority of infliximab infusions were administered at less than or equal to the number of vials expected for a 3 mg/kg dose (the minimum recommended dose). While these results indicate that a large-scale initiative to improve prescribing of TNF inhibitors may not be needed, a further understanding of the factors that lead to prescribing of high doses of TNF inhibitors might be warranted.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

BackgroundEffective influenza surveillance and communication of influenza activity are crucial for the management of influenza outbreaks. The accuracy of clinical diagnoses can be enhanced if the influenza virus is known to be circulating in the community.ObjectiveTo report on the development of a new influenza surveillance system in Germany (2001–2002) based on consultation rates and near patient test results using the Influenza A/B Rapid Test (IRT) and RealFlu™ Surveillance methodology.MethodsThis is the first internationally standardized, rapid influenza surveillance system providing harmonized influenza-specific information. RealFlu™ Surveillance is unique in its approach by generating two baselines: one with morbidity rates and one with specific influenza activity based on near patient test results. The baselines are set independently for each participating country and its constituent regions, thereby allowing monitoring of national as well as regional influenza activity. The system is highly specific and sensitive to influenza and differentiates between three levels of the RealFlu™ Surveillance influenza activity:no/sporadic activity;moderate activity; andhigh activity.Weekly activity is presented in graphs, maps, and data tables with daily updates and comments. In this report, data collected during the influenza season 2001–2002 in Germany are presented.ResultsThe RealFlu™ Surveillance system has been running for four consecutive influenza seasons since 1999. The first increase in influenza circulation was seen from week 2 (from year start) to week 4. In week 5, a steep increase in influenza positives was observed. A significant amount of excess morbidity was seen from week 7, peaking in week 11. The season started in western regions of Germany and ended in eastern regions of Germany. Regional outbreaks were detected also when the aggregated country data did not indicate any significant increase in influenza activity.ConclusionBy providing specific, real-time monitoring of regional and national influenza outbreaks, the RealFlu™ Surveillance system complements existing schemes and presents a practical surveillance methodology for countries where influenza surveillance does not exist.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Eptifibatide (Integrilin®) is a selective inhibitor of platelet glycoprotein IIb/IIIa receptors used as adjunctive therapy for patients undergoing percutaneous coronary intervention (PCI) and for patients with acute coronary syndromes (ACS), particularly those requiring PCI. Most economic analyses of eptifibatide have incorporated clinical and healthcare resource use data from either the ESPRIT (Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin®Therapy) study in low- to moderate-risk patients undergoing selective PCI with stent implantation or the PURSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin®Therapy) trial in patients with ACS. Eptifibatide achieved statistically significant reductions in combined endpoints of death and ischemic complications in both of these large multicenter clinical trials, in which patients were randomized to receive intravenous eptifibatide or placebo as adjunctive therapy to heparin and aspirin (plus a thienopyridine in ESPRIT).In US economic analyses using ESPRIT trial data, approximately 40% and 70% of the acquisition cost of eptifibatide was offset by reduced medical resource consumption during the initial hospitalization period and over a 1-year period, respectively. Eptifibatide was associated with a favorable cost-effectiveness ratio of $US1407 (year 2000 values) per life-year gained (LYG) in a retrospective US cost-effectiveness analysis that incorporated data from the ESPRIT trial and modeled life expectancy using a large cardiovascular database.Several cost-effectiveness analyses used prospectively collected data from the PURSUIT trial and modeled survival projections using similar methods. These analyses, conducted in the US, Canada, and Western Europe, also showed favorable results ($US3761–$US18 774 per LYG; various years of costing). Cost-utility ratios reported in US analyses varied somewhat, but remained <$US20 000 per quality-adjusted life-year gained (1996 values) when clinical efficacy data were derived from the US cohort of PURSUIT.In conclusion, significant clinical benefits have been demonstrated with eptifibatide as adjunctive therapy in patients undergoing selective PCI with stent implantation in the ESPRIT trial and in patients with ACS in the PURSUIT trial. Pharmacoeconomic analyses using data from either ESPRIT or PURSUIT have demonstrated favorable cost-effectiveness ratios for both indications in various countries. ESPRIT-based results from the limited number of available economic analyses are particularly favorable. The cost-effectiveness of eptifibatide in ACS (i.e. PURSUIT-based results) may be further improved by targeting the drug for patients in whom catheterisation and PCI are planned, although further analyses are required to confirm this.

ISSN:1173-8790    

出版商:ADIS    

年代:2004

数据来源: ADIS