摘要:

ObjectiveThe primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and settingEffectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.PatientsPatients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and resultsResults demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA1c) values from 9.31 to 7.21 (p < 0.001). The HbA1cvalue for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1cvalues less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.ConclusionsOur results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient's primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

ObjectiveTo describe the cost savings achieved in a health maintenance organization (HMO)-sponsored primary care-based case management and disease management programs.MethodsThe HMO-sponsored programs recruited patients in the primary care setting and relied on clinical guidelines and HMO-employed patient education nurses and case management nurses. Total per member per month (PMPM) charges for medical services and changes in selected clinical outcomes before and after entry into HMO-sponsored case management and disease management programs for actively enrolled participants were compared during the fiscal year January 1, 1998 to November 31, 2000.InterventionsThe disease management programs addressed asthma, diabetes mellitus and congestive heart failure (CHF). These programs were based on a network of primary care-based nurse educators and case managers promoting clinical guidelines, appropriate use of the insurance benefit, community-based resources, and communication among all healthcare providers.Setting and participantsThis initiative was based in 55 primary care sites serving 295 000 insureds across northeastern and central Pennsylvania, USA.Results396 patients with asthma had mean baseline PMPM charges of $US298, which decreased to $US276 PMPM after entry. In those with diabetes mellitus, 3556 patients had a mean baseline PMPM charge of $US367 that decreased to $US346. The mean baseline PMPM charge decreased from $US1877 to $US1541 for 1795 patients with CHF. For 3346 patients undergoing case management, the mean baseline PMPM charge was $US1991 and it decreased to $US1545. Total mean reductions in claims over one year of follow-up from the day of entry for patients with asthma, diabetes mellitus, CHF and for case management programs were $US105 544, $US896 112, $US7 237 440 and $US17 907 992, respectively.Additional data regarding asthma-only claims and pre-post days of work loss in the previous six months, diabetes mellitus-only claims and pre-post mean glycosylated hemoglobin A1cvalues, inpatient and outpatient CHF total claims, ACE inhibitor use in CHF, and inpatient and outpatient total claims in case management are also provided.ConclusionWhile these claims data may be limited by a lack of statistical significance and by regression to the mean, they suggest that case management and disease management programs in asthma, diabetes and congestive heart failure can be associated with significant financial savings compared with baseline levels of utilization. Clinical outcomes data also suggest this approach may be of benefit.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Rheumatoid arthritis is associated with substantial costs to both the individual and society; costs increase as disease severity worsens. Current thinking is that disease-modifying antirheumatic drug (DMARD) therapy should be started as soon as possible after the diagnosis of rheumatoid arthritis and that patients should be offered the most effective treatment available.Etanercept is a soluble dimeric fusion protein comprising two copies of the extracellular ligand-binding domain of the human p75 receptor for tumour necrosis factor-α (TNFα) linked to the constant portion of human immunoglobulin G1. TNFα is thought to play an important role in the pathophysiology of rheumatoid arthritis; by binding the cytokine, etanercept blocks its biologic effects.In a 12-month double-blind, randomized study involving patients with early active rheumatoid arthritis, administration of subcutaneous etanercept 25mg twice weekly was associated with a more rapid and significantly greater overall response (assessed using American College of Rheumatology criteria) than oral methotrexate. In addition, compared with methotrexate, etanercept was associated with more rapid slowing of radiographic progression and a more rapid improvement in measures of health-related quality of life. The efficacy of etanercept was maintained at 3 years' follow-up.Etanercept, alone or in combination with methotrexate, also showed sustained efficacy in three double-blind, randomized, placebo-controlled studies of 3 to 6 months' duration involving patients with active rheumatoid arthritis who had not responded adequately to previous treatment with DMARDs.Etanercept was generally well tolerated in clinical trials (the most commonly occurring adverse events included injection site reactions, infection, headache, nausea, rhinitis, dizziness, pharyngitis and cough).The high cost of etanercept relative to traditional DMARDs may be justified if it can be shown to reduce long-term outcomes associated with rheumatoid arthritis, thereby reducing disease costs.ConclusionEtanercept is an important new treatment option in rheumatoid arthritis. It provides a rapid and sustained reduction in disease activity and inhibits the progression of structural damage in patients with early active rheumatoid arthritis, with good tolerability. The improvement in disease activity and slowing of joint damage seen with etanercept was more rapid than that seen with methotrexate. In addition, etanercept, alone or in combination with methotrexate, is effective in the treatment of patients with active rheumatoid arthritis who have not responded adequately to previous DMARD therapy. It is anticipated that etanercept may also improve the long-term outcome of patients with rheumatoid arthritis and reduce the substantial economic burden imposed by the disease; however, more long-term data are needed to establish this.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Alzheimer's disease affects 15 million people worldwide. As the elderly population grows, the incidence of Alzheimer's disease will also increase. It is estimated that by 2010, 40 million US citizens will be over the age of 65 years and by 2040, it is predicted that 14 million US citizens will have Alzheimer's disease. There is currently no treatment which stops or delays the progression of this condition; however, anticholinesterase therapy provides some symptomatic relief. The cognitive impairment experienced by patients with Alzheimer's disease is partially due to degeneration of cholinergic pathways within the CNS and therefore symptomatic treatments have focused on restoring cholinergic inputs.Donepezil is a second generation anticholinesterase drug which reduces cortical acetylcholinesterase activity and improves, or at least slows the decline in, cognitive functioning in patients with Alzheimer's disease. In patients with mild to moderate Alzheimer's disease, treatment with donepezil (5 to 10 mg/day) for 1 year extended the median time to a clinically evident functional decline by 5 months compared with treatment with placebo. In addition, patients receiving donepezil have also shown significant improvement in ratings of global function, cognition, activities of daily living and disease severity over a 1-year period (p < 0.05 in each case). In patients with moderate to severe Alzheimer's disease, donepezil significantly improved ratings of behavior compared with placebo (p < 0.05).Donepezil treatment is associated with the well recognized adverse events which accompany cholinergic therapy. The most frequently reported adverse events with donepezil treatment are gastrointestinal complaints such as nausea, diarrhea and vomiting, and CNS conditions including dizziness, headache and insomnia. These adverse events are typically mild and transient. Preliminary data from a direct comparison of donepezil and rivastigmine suggests that donepezil may exhibit an improved tolerability profile compared with rivastigmine.Recent data suggest that use of donepezil is associated with a significant delay in the time to institutionalization. Data from modeling and pharmacoeconomic studies also predict that use of donepezil may lead to a reduction in costs. However, it is likely that these savings will be distributed across multiple healthcare and non-healthcare systems and may not be fully represented in the budgets of those who are responsible for the direct costs of providing this medication.Donepezil is the only cholinesterase inhibitor currently available in a once daily formulation and with a relatively simple dose escalation schedule. This regimen coupled with a good tolerability profile makes donepezil a first-line treatment for patients with mild to moderate Alzheimer's disease. However, only direct comparisons between donepezil and other second generation anticholinesterases will provide definitive data which can be used to maximize patient outcomes. In addition, wider clinical experience with donepezil may help to identify a subgroup of patients who respond strongly to treatment thus improving patient care and reducing costs.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

The clinical course of chronic bronchitis is intermittently interrupted by acute exacerbations (AECB), especially during the winter months, characterised by an increase in cough, a change in the purulence and volume of sputum, or worsening of dyspnea. Although AECB can be caused by allergens, pollutants, inhaled irritants or viral infections, or by endogenous conditions such as left heart failure, most AECB are precipitated by bacterial infections (ABECB).Patients with chronic bronchitis are estimated to have an average of one to four acute exacerbations per year. The total annual cost of treatment of patients with AECB in the US was calculated to be $US1.2 billion for those aged ≥65 years and $US419 million for those aged <65 years (1995 costs). Hospitalization accounted for >95% of these costs. After an acute exacerbation, most patients experience a transitory or permanent decrease in quality of life. It is important that the initial antibacterial therapy is successful as treatment failure can lead to further more costly treatment, especially if hospitalization is required. Thus, treatment regimens that allow patients to be treated successfully as outpatients are likely to be associated with considerable financial benefits.The nontypeable strains ofHaemophilus influenzaeare the commonest etiological organism for AECB; β-lactamase-mediated amoxicillin resistance can be expected in 20 to 40% ofH. influenzaestrains in North America and southern European countries. Strains resistant to trimethoprim, tetracyclines and chloramphenicol are also being increasingly identified. More than 90% of strains ofMoraxella catarrhalis, another important etiological agent for AECB, are resistant to amoxicillin in North America and Europe.Streptococcus pneumoniaeaccounts for about 20% of cases of AECB. During the last three decades, the increase in incidence ofS. pneumoniaestrains with decreased susceptibility to penicillin has been a serious concern worldwide. Additionally, the use of fluoroquinolones with suboptimal activity againstS. pneumoniae(e.g. ciprofloxacin, levofloxacin) has resulted in the appearance of mutations with fluoroquinolone resistance. So it is important that fluoroquinolones used to treat AECB have high levels of activity againstS. pneumoniaeat clinically achievable serum levels.Moxifloxacin shows goodin vitroactivity against all of the common pathogens associated with ABECB, such asH. influenzae,S. pneumoniaeandM. catarrhalis. Moxifloxacin administered orally, shows good clinical and bacteriological efficacy in the treatment of ABECB. The clinical and bacteriological efficacy of moxifloxacin in the treatment of ABECB was equivalent to that of clarithromycin, azithromycin, levofloxacin and amoxicillin/clavulanic acid in randomized, comparative trials. No strain of the three common organisms responsible for ABECB resistant to moxifloxacin has been detected. Moxifloxacin has also been shown to relieve the symptoms of ABECB more rapidly then azithromycin. In addition, patients with ABECB treated with moxifloxacin have been shown to have better productivity at work than those treated with levofloxacin.Moxifloxacin offers the advantage of once-daily administration and has a low potential for drug interactions. Moreover, dosage adjustment is not required for elderly patients or for those with any degree of renal impairment, or mild or moderate hepatic impairment. The drug is administered as a short, (five day) treatment course and this is likely to be beneficial in terms of patient compliance.Moxifloxacin is generally well tolerated, with most the common adverse event being gastrointestinal disturbance. The drug has been associated with a small degree of prolongation of QTc (mean increase of 6msec). torsade de pointes was reported at a rate of less than 1 per 2 million patient uses. These events occurred in patients with predisposing factors.ConclusionsMoxifloxacin is a broad spectrum antibacterial agent with excellent activity against the common pathogens (including penicillin-resistantS. pneumoniae) involved in ABECB. The drug has a favorable tolerability profile, a low potential for drug interactions and is administered as a convenient once-daily regimen. In addition, it can be used without dosage modification in the elderly and in patients with any degree of renal impairment or mild or moderate hepatic impairment. Moxifloxacin may be considered a good initial option for the treatment of patients with moderate to severe ABECB who are identified to be at risk for treatment failure with current first-line agents and in those who do not respond to initial treatment with other agents.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

The rapid expansion of disease management continues. A multitude of stakeholders and marketplaces are now involved in providing cost-effective quality healthcare for individuals and populations. To help you keep up-to-date with the very latest developments in disease management, this section of the journal brings you information selected from the disease management and pharmacoeconomic reporting servicePharmacoEconomics & Outcomes News Weekly.1The following reports are selected from the very latest to be published across a broad range of literature sources.

ISSN:1173-8790    

出版商:ADIS    

年代:2002

数据来源: ADIS