Evaluation of rationality in prescribing, adherence to treatment guidelines, and direct cost of treatment in intensive cardiac care unit: A prospective observational study

Projected Cost-Effectiveness for 2 Gene-Drug Pairs Using a Multigene Panel for Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

For patients undergoing percutaneous coronary intervention, gene-drug associations exist relevant to first-line treatment options-antiplatelet agent, clopidogrel, and pain medication, tramadol. Knowledge of genotype information may allow for avoidance of adverse drug events during critical clinical windows.

OBJECTIVE

This evaluation estimated cost-effectiveness associated with a multi-gene panel pre-emptively testing two genes providing CYP2C19 genotype-guided strategy for antiplatelet therapy, with CYP2D6 genotype-guided pain management, compared to single gene test for CYP2C19 with random assignment for pain treatment, and to no testing (empiric clopidogrel with random assignment for pain treatment).

METHODS

Decision analysis modeling was used to project costs from a payer perspective and patient quality-adjusted life years (QALYs) from the three strategies. The model captured composite risks of major adverse cardiovascular events and pain therapy-related adverse drug events and associated utility estimates. We conducted sensitivity analyses to assess influential input parameters.

RESULTS

Over 15 months, multi-gene testing was least costly and yielded more QALYs compared to both single gene and no testing; total incremental costs were $1646 lower with incremental gains of 0.04 QALYs for multi-gene compared with single gene and $11 368 lower with 0.17 QALY gains compared to no test. Base case analyses revealed multi gene was dominant compared to both single gene and no test, as it demonstrated cost savings with increased QALYs.

CONCLUSIONS

For these patients, a multi-gene-guided strategy yields a favorable incremental cost-effectiveness ratio compared to the other two treatment strategies. Pre-emptively ascertaining additional gene-drug pair information can inform clinical and economic decision-making at the point of care.

Initiation of antiretroviral therapy based on the 2015 WHO guidelines

OBJECTIVE

In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/μl in four resource-limited countries (South Africa, Nigeria, Uganda, and India).

DESIGN

A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/μl initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/μl were met.

METHODS

The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds.

RESULTS

Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions.

CONCLUSIONS

In HIV-positive patients with CD4 counts above 500 cells/μl in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.

Prevalence of potentially inappropriate medications and prescription cost analysis among older cardiac patients in an outpatient department of a tertiary care hospital in India

Aims:

The aim of this study is to evaluate potentially inappropriate medications (PIMs) in the elderly at cardiology outpatient department (OPD) of a tertiary care teaching hospital using Beers criteria and to find the direct cost burden of PIMs.

Materials and Methods:

The present study was an observational cross-sectional study. Prescriptions of the patients’ aged ≥65 years were collected from the cardiology OPD and were analyzed. PIMs were identified with the help of Beers 2012 criteria. Direct costs of prescribed drugs were calculated. Predictors (comorbid conditions, number of drugs prescribed) associated with PIM use were identified using bivariate analysis. Multivariate logistic regression was then applied to study the influence of these variables on PIM use. A P < 0.05 was considered statistically significant.

Results:

A total of 236 patients received 1443 drugs. According to Beers 2012 criteria, 29.3% patients received at least one PIM followed by two and three PIMs in 10 and 23 patients, respectively. The most commonly prescribed PIM was spironolactone in 15.7% patients followed by benzodiazepines in 15 patients. The total cost of therapy for 1 day was Indian Rupee (INR) 10,029.2 while total cost of all prescribed medications in per day was INR 42.5.

Conclusions:

This study showed higher use of PIMs among the elderly in cardiac OPD. It is important to improve the situation of older cardiac patients who have higher use of PIMs. In older patients, high prevalence of PIMs was associated with increased cost. The use of regular continuing medical education program by the hospital and educating and training doctors on rational prescribing will help alleviate this issue.