Disparities in timeliness of care for U.S. Medicare patients diagnosed with cancer

BACKGROUND

Timeliness of care (rapid initiation of treatment after definitive diagnosis) is a key component of high-quality cancer treatment. The present study evaluated factors influencing timeliness of care for U.S. Medicare enrollees.

METHODS

Data for Medicare enrollees diagnosed with breast, colorectal, lung, or prostate cancer while living in U.S. seer (Surveillance, Epidemiology and End Results) regions in 2000-2002 were analyzed. Patients were classified as experiencing delayed treatment if the interval between diagnosis and treatment was greater than the 95th percentile for each cancer site. The impacts of patient sociodemographic, clinical, and area-based factors on the likelihood of delayed treatment were analyzed using multivariate logistic regression.

RESULTS

Black patients (compared with white patients) and patients initially treated with radiation therapy or chemotherapy (rather than surgery) had a greater likelihood of treatment delays across all four cancer sites. Hispanic status, dual Medicare-Medicaid status, location of initial treatment (inpatient vs. outpatient), and stage at diagnosis also affected timeliness of care for some cancer sites. Surprisingly, area-based factors reflecting availability of cancer care services were not significantly associated with timeliness of care or were associated with greater delays in areas with greater numbers of service providers.

CONCLUSIONS

Multiple factors affected receipt of timely cancer care for members of the study population, all of whom had coverage of medical care services through Medicare. Because delays in treatment initiation can increase morbidity, decrease quality of life, shorten survival, and result in greater costs, prospective studies and tailored interventions are needed to address those factors among at-risk patient groups.

From research to practice: factors affecting implementation of prospective targeted injury-detection systems

AIM This paper describes key factors that shaped implementation of prospective targeted injury-detection systems (TIDS) for adverse drug events (ADEs) and nosocomial pressure ulcers (PrU). METHODS Using case-study methodology, the authors conducted semistructured interviews with implementation champions and TIDS users at five hospitals. Interviews focused on implementation experiences, assessment of TIDS' effectiveness and utility, and plans for sustainability. The authors used content analysis techniques to compare implementation experiences within and across organisations and triangulated data for explanation and confirmation of common themes. FINDINGS Participating hospitals were more successful in implementing the low-complexity PrU-TIDS, as compared with high-complexity ADE-TIDS. This pattern reflected the greater complexity of ADE-TIDS, its higher costs and poorer alignment with existing workflows. Complexity affected the innovations' perceived usability, the time needed to learn and install the trigger systems, and their costs. Local factors affecting implementation and sustainability of both innovations included turnover affecting champions and other staff, shifting organisational priorities, changing information infrastructures, and institutional constraints on adapting existing IT to the electronic TIDS. CONCLUSIONS To facilitate implementation of complex healthcare innovations such as ADE-TIDS, staff in adopting organisations should give high priority to innovation implementation; allocate sufficient resources; effectively communicate with and involve local champions and users; and align innovations with workflows and information systems. In addition, they should monitor local factors, such as changes in organisational priorities and IT, availability of implementation staff and champions, and external regulations and constraints that may pose barriers to innovation implementation and sustainability.

Patient and health system disparities in timeliness of treatment for individuals with colorectal cancer (CRC)

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Background: Timely initiation of treatment following cancer diagnosis can improve morbidity, quality of life, and survival. We used SEER-Medicare data for individuals diagnosed with CRC to explore disparities in the timeliness of initial cancer therapy. Methods: Medicare patients diagnosed with CRC in 2000–2001 while living in SEER regions were identified. Only patients who received cancer treatment (surgery, radiation therapy, or chemotherapy), were diagnosed at age 66 or later, and were enrolled in Medicare at least one year post-diagnosis were included. Multivariate logistic regression analysis was used to evaluate the impact of patient sociodemographic, clinical, community, and health system factors on receipt of timely care, defined as treatment initiation within the 95th percentile of waiting time for all CRC patient (two months). Results: Black and Hispanic CRC patients were significantly more likely to experience delays in treatment than were White patients. Males and patients from areas with more non-English speakers were also more likely to experience delays. Among earlier stage patients who received surgery, those treated at physician offices (10.2%) were significantly more likely to experience delays than were those treated at hospitals (as inpatients or outpatients). Among patients with distant stage disease, those initially treated as hospital inpatients were significantly less likely to experience delays than were those treated as hospital outpatients or in physician offices. For these patients, initial treatment with chemotherapy or radiation therapy was associated with significantly greater likelihood of delays compared to patients initially receiving surgery. Conclusions: Controlling for other factors, significant disparities in timeliness of care were observed for racial/ethnic minority patients, males, and those from non-English speaking areas. Treatment site and modality also affected timeliness of care. While more research is needed, programs should target these at-risk populations for education and follow-up after diagnosis.

No significant financial relationships to disclose.

Impact of adalimumab on work participation in rheumatoid arthritis: comparison of an open-label extension study and a registry-based control group

Background and objectives:

Rheumatoid arthritis (RA) causes considerable disability and often results in loss of work capacity and productivity. This study evaluated the impact of adalimumab, a tumour necrosis factor antagonist with demonstrated efficacy in RA, on long-term employment.

Methods:

Data from an open-label extension study (DE033) of 486 RA patients receiving adalimumab monotherapy who previously did not respond to at least one disease-modifying antirheumatic drug (DMARD) and had baseline work status information were compared with data from 747 RA patients receiving DMARD treatment in a Norway-based longitudinal registry. Primary outcomes included the time patients continued working at least part time and the likelihood of stopping work. Secondary outcomes included American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) responses and disease remission. Outcomes were compared 6, 12 and 24 months after enrolment.

Results:

During a 24-month period, the 158 patients who received adalimumab and were working at baseline worked 7.32 months longer (95% CI 4.8 to 9.1) than did the 180 patients treated with DMARDs, controlling for differences in baseline characteristics. Regardless of baseline work status, patients receiving adalimumab worked 2.0 months longer (95% CI 1.3 to 2.6) and were significantly less likely to stop working than those receiving DMARDs (HR 0.36 (95% CI −0.30 to 0.42) for all patients and 0.36 (95% CI 0.15 to 0.85) for patients working at baseline, respectively). The patients who received adalimumab were also considerably more likely to achieve ACR responses and disease remission than DMARD-treated patients. Patients who achieved EULAR good response and remission were less likely to stop working, but this relationship was only seen in patients receiving DMARDs.

Conclusions:

Patients with RA who received adalimumab experienced considerably longer periods of work and continuous employment, and greater rates of clinical responses, than patients receiving DMARDs. The mechanism by which adalimumab decreases likelihood of stopping work seems to be different from that of DMARD treatment and independent of clinical responses.

Economic burden of revision hip and knee arthroplasty in Medicare enrollees

The economic burden to Medicare due to revision arthroplasty procedures has not yet been studied systematically. The economic burden of revisions was calculated as annual reimbursements for revision arthroplasties relative to the sum total reimbursements of primary and revision arthroplasties. We evaluated this revision burden for total hip and knee arthroplasties through investigation of trends in charges and reimbursements in the Medicare population (Parts A and B claims from 1997-2003), while taking into account age and gender effects. Mean annual economic revision burdens were 18.8% (range, 17.4-20.2%) and 8.2% (range, 7.5-9.2%) for total hip arthroplasties and total knee arthroplasties, respectively. Procedural charges increased while reimbursements decreased over the study period, with higher charges observed for revisions than primary arthroplasties. Reimbursements per procedure were 62% to 68% less than associated charges for primary and revision total hip and knee arthroplasties. The effect of age and gender on reimbursements varied by procedure type. Unless some limiting mechanism is implemented to reduce the incidence of revision surgeries, the diverging trends in reimbursements and charges for total hip and knee arthroplasties indicate that the economic impact to the Medicare population and healthcare system will continue to increase.

LEVEL OF EVIDENCE

Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.

Economic analysis of the Confronting COPD survey: methodology

Chronic obstructive pulmonary disease (COPD) is a condition characterized by progressive airflow limitation, which causes considerable morbidity and mortality worldwide. Yet the burden of COPD is poorly recognized, and the disease remains an inadequately managed health problem. Few studies have attempted to quantify the impact of the disease on patient health, the healthcare system and society as a whole. This provided the rationale for Confronting COPD in North America and Europe, the first large-scale international survey of the burden of COPD. This paper describes how quantitative measures of healthcare resource utilization and workplace productivity loss were derived from patient responses to the Confronting COPD survey, to investigate the country-specific impact of COPD on the healthcare system and society. The aim of this analysis is to inform countries of the economic impact of the condition, and demonstrate the need for better COPD treatment to improve health and reduce the sizeable burden of this disease.

The burden of COPD in the U.S.A.: results from the Confronting COPD survey

Chronic obstructive pulmonary disease (COPD) is a progressive disorder of airflow limitation that is not fully reversible, with disabling symptoms including chronic cough and dyspnoea. Although a number of studies in the U.S.A. have assessed the impact of COPD on the healthcare system and society, data on healthcare resource utilization (particularly outpatient services and medication use) in patients with mild to moderate COPD, or patients who meet symptom criteria for COPD but have not received this diagnosis, are limited or unavailable. To fill gaps in current knowledge about the impact of this disease, an economic analysis was conducted on the data collected from patients enrolled in the U.S.A. sample of Confronting COPD in North America and Europe, the first large-scale international survey of the burden of the disease. The annual cost of healthcare resource utilization was estimated at US dollar 4119 per patient with COPD, with indirect (non-medical care) costs amounting to US dollar 1527 per patient. The annual estimated societal cost was therefore US dollar 5646 per patient. The majority of disease costs in the survey were associated with inpatient hospitalizations (US dollar 2891). The results of the survey suggest that interventions that improve COPD outcomes by decreasing symptoms and preventing acute exacerbations could substantially decrease the costs associated with this disease.

Impact of smoking status on workplace absenteeism and productivity

OBJECTIVES

To: evaluate the impact of smoking status on objective productivity and absenteeism measures; evaluate the impact of smoking status on subjective measures of productivity; and assess the correlation between subjective and objective productivity measures.

DESIGN

Prospective cohort study in a workplace environment.

SUBJECTS

Approximately 300 employees (100 each of former, current, and never smokers) at a reservation office of a large US airline.

MAIN OUTCOME MEASURES

Objective productivity and absenteeism data were supplied by the employer. Subjective assessments of productivity were collected using a self report instrument, the Health and Work Questionnaire (HWQ).

RESULTS

Current smokers had significantly greater absenteeism than did never smokers, with former smokers having intermediate values; among former smokers, absenteeism showed a significant decline with years following cessation. Former smokers showed an increase in seven of 10 objective productivity measures as compared to current smokers, with a mean increase of 4.5%. While objective productivity measures for former smokers decreased compared to measures for current smokers during the first year following cessation, values for former smokers were greater than those for current smokers by 1-4 years following cessation. Subjective assessments of "productivity evaluation by others" and "personal life satisfaction" showed significant trends with highest values for never smokers, lowest for current smokers, and intermediate for former smokers.

CONCLUSIONS

Workplace productivity is increased and absenteeism is decreased among former smokers as compared to current smokers. Productivity among former smokers increases over time toward values seen among never smokers. Subjective measures of productivity provide indications of novel ways of productivity assessment that are sensitive to smoking status.

Impact of poorly controlled hypertension on healthcare resource utilization and cost

OBJECTIVE

To examine the relation between blood pressure (BP) control and utilization and cost of healthcare resources.

STUDY DESIGN

A retrospective database study of managed care patients in New Mexico from January 1, 1996, to December 31, 1997.

PATIENTS AND METHODS

We stratified 1000 hypertensive patients into categories based on average and maximum BP. Antihypertensive medication use and cost, number of physician visits, and interval between hypertension-related physician visits were determined.

RESULTS

Medication costs increased progressively across all BP categories from lowest to highest, and higher average systolic BP (SBP) was significantly correlated with increased cost (P < .001). There were significant correlations between higher maximum BP and greater number of hypertension-related physician visits (P < .001). Mean number of visits for BP groups was 5.5 for patients with a maximum diastolic BP (DBP) < 85 mm Hg and 10.0 for those with a maximum DBP > or = 100 mm Hg (P < .001). Patients with a maximum SBP > or = 180 mm Hg averaged 9.7 visits, whereas those with a maximum SBP < 120 mm Hg averaged 4.1 visits (P < .001). Both SBP and DBP were significantly correlated with time to next visit (P < .001). Mean visit intervals ranged from 44 days for patients with an SBP < 85 mm Hg to 25 days for those with an SBP > or = 180 mm Hg (P < .001). A similar association was found between DBP and visit interval.

CONCLUSIONS

Poor control of hypertension is associated with higher drug costs and more physician visits. Aggressive treatment might help reduce managed care costs and resource utilization.

Cost-effectiveness of the conventional papanicolaou test with a new adjunct to cytological screening for squamous cell carcinoma of the uterine cervix and its precursors

OBJECTIVE

To estimate costs and outcomes of conventional annual Papanicolaou (Pap) test screening compared with biennial Pap test plus speculoscopy (PPS) screening for cervical neoplasms.

DESIGN

A Markov model compared cost-effectiveness and outcomes of annual Pap tests with biennial PPS. The model includes direct costs of screening, diagnostic testing, and treatment for squamous intraepitheial lesions and invasive cancers; indirect costs (eg, lost productivity because of cervical cancer); and newer management practices, including human papillomavirus DNA testing.

PATIENTS

Women aged 18 to 64 years.

INTERVENTION

Screening for cervical neoplasms with either annual Pap smear test or biennial PPS.

MAIN OUTCOME MEASURE

Marginal cost per life-year gained.

RESULTS

The probability of women having squamous intraepithelial lesions, cervical cancer, or death from cervical cancer was lower among women undergoing PPS biennially. A total of 12 additional days of life per woman was gained with biennial PPS during the 47-year model period. Total average cumulative direct medical costs per patient were $1419 for biennial PPS compared with $1489 for annual Pap tests. Total costs, including direct medical costs and indirect costs, were $2185 for PPS compared with $3179 for Pap tests alone. Increased savings and patient outcomes were observed in high-risk populations.

CONCLUSION

Our simulations indicate that biennial screening with PPS is expected to provide cost savings for women older than 18 years compared with annual Pap test screening, especially for those in high-risk populations.

Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs

The development and application of an economic model designed to assess the specific costs and benefits of health plan coverage of smoking-cessation programs involving sustained-release bupropion hydrochloride are described. A cohort of 100,000 employees or health plan members and 60,000 adult dependents was followed from the start of the model to either retirement at age 65 or death at age 85. The model was used to compare outcomes for coverage versus no coverage of sustained-release bupropion hydrochloride as a component of a smoking-cessation benefit under four managed care plan scenarios and four employer scenarios. For the managed care scenarios involving coverage of bupropion sustained-release the overall decrease in health care costs over a 20-year period ranged from $7.9 million to $8.8 million; for every dollar spent covering smoking cessation, $4.10-$4.69 in health care costs was saved. For the employer scenarios, health care costs over 20 years decreased by $8.3 million to $14.0 million, and smoking-related indirect costs decreased an additional $5.1 million to $7.7 million; for every dollar spent covering smoking cessation, $5.04-$6.48 was saved. A model developed to assess the specific costs and benefits of covering sustained release bupropion hydrochloride as a component of a smoking-cessation benefit indicated cost savings for health plans and employers.

Cost-effectiveness of cesarean section delivery to prevent mother-to-child transmission of HIV-1

OBJECTIVE

To evaluate costs and outcomes of cesarean section performed before onset of labor and before rupture of membranes (elective cesarean section) compared to vaginal delivery among HIV-infected women.

DESIGN

Cost-effectiveness and cost-benefit analysis.

PARTICIPANTS AND SETTING

Pregnant HIV-infected women in the US who refrain from breastfeeding.

INTERVENTION

Elective cesarean section versus vaginal delivery by antiretroviral therapy regimen.

MAIN OUTCOME MEASURES

Pediatric HIV cases avoided, years of life saved, and direct medical costs for maternal interventions and pediatric HIV treatment.

RESULTS

Elective cesarean section (versus vaginal delivery) was cost-effective among women receiving zidovudine prophylaxis (US$1131 per case avoided, US$17 per year of life saved) and combination antiretroviral therapy (US$112693 per case avoided, US$1697 per year of life saved), and cost saving among women receiving no antiretroviral therapy during pregnancy (benefit-cost ratio of 2.23). Although elective cesarean section remained cost-effective, results were sensitive to variations in vertical transmission rates and to pediatric HIV treatment costs. Population-based analyses indicated that elective cesarean section could prevent 239 pediatric HIV cases annually with a savings of over US$4 million.

CONCLUSIONS

Elective cesarean section is a cost-effective intervention to prevent vertical transmission of HIV among women receiving various antiretroviral therapy regimens, who refrain from breastfeeding.

Smoking cessation in hospitalized patients

The components of readiness to change for smoking cessation that are found in the general population are also applicable to hospitalized smokers. Smoking cessation interventions must be specifically tailored to subgroups among hospitalized patients, with emphasis on smoking-related diagnosis when applicable. Interventions should include key components related to smoking cessation, such as knowledge, self-efficacy, exposure to smoking, and social support. Interventions that include relapse prevention and are conducted in the context of other risk reduction strategies should be developed.

Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin

OBJECTIVE

The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy.

METHODS

Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient.

RESULTS

The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from $457 to $994 per patient.

CONCLUSIONS

The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

The relation of patient satisfaction with treatment of otitis externa to clinical outcomes: development of an instrument

This survey was undertaken to develop a short, comprehensive measure of patient satisfaction with pharmacologic treatment for otitis externa and to assess the relationships between satisfaction, disease symptoms, and medication side effects. Otitis externa was diagnosed in 41 patients recruited from 6 sites; 34 patients completed and returned the study instruments and were included in the study. Patients or their caregivers administered polymyxin/neomycin/hydrocortisone ear drops prescribed by a physician and completed a daily diary for 10 days and a satisfaction questionnaire at the end of the treatment period. The main outcome measures were the subscale scores for patient satisfaction and their relation to medication side effects, symptoms of ear infection, activity limitations, pain, and adherence to prescription regimens. The questionnaire and its subscales demonstrated good psychometric properties (ie, reliability coefficients >0.75, except for 1 subscale). Overall satisfaction was found to be significantly correlated with relief of symptoms, ability to return to normal activities, ease of administration, and medication side effects. Satisfaction subscale scores were correlated with patient-reported severity of medication side effects and disease symptoms. More than half the patients took drops for more than the prescribed number of days, and one third took more than the prescribed number of drops per administration (ie, overadherence). The relation between satisfaction and adherence was weak, perhaps due to the high rates of overadherence. Our results demonstrate that patient satisfaction with otic medication can be assessed across various aspects of satisfaction and that it is correlated with reported disease symptoms and medication side effects. This type of multifaceted assessment may help physicians select between medications with different side-effect profiles and administration schedules. Larger studies are needed to evaluate the relationship between satisfaction with an otic medication and adherence to a medication regimen.

Health-related quality of life evaluations of gastric and pancreatic cancer

This review addresses the state of the literature on health-related quality of life (HRQL) assessment among patients with cancers of the pancreas and stomach. We first briefly review the epidemiology of these cancers. We examine the concept of HRQL and the degree to which it has been measured among these patient groups. The impact of gastric and pancreatic cancers on HRQL is described, including the domains which these conditions are most likely to impact. The effect of different treatments on HRQL is considered, including surgical procedures, pharmacological and non-pharmacological therapies, and procedures for symptom palliation. Based on our findings on the limited quantity and quality of the body of literature, we make suggestions for further research in the area. Results suggest three areas in which HRQL can play an important role in the study of gastric and pancreatic cancer. First, future investigations should consider both survival and HRQL in comparing surgical procedures. Second, studies of chemotherapy should include HRQL evaluation, with careful attention to conducting assessments at times appropriate to capture the effects of chemotherapy. Third, studies of the impact of palliative care should include assessments of HRQL.

Multihospital system affiliation as a survival strategy for rural hospitals under the prospective payment system

The introduction of Medicare's Prospective Payment System (PPS) has disproportionately increased financial pressures on rural hospitals and posed challenges to the survival of these institutions. Increasingly, rural hospitals are seeking strategies that can enhance their chances for survival in a turbulent and hostile environment. This study examined the survival effects of one such strategy, multihospital system affiliation. Specifically, we assessed: (1) whether and how different types of system affiliation in the post-PPS era affect the likelihood of rural hospital survival; (2) whether particular structural, environmental and hospital performance characteristics moderate the effects of system affiliation on rural hospital survival; and (3) whether systematic selection by rural hospitals into multihospital systems potentially accounts for observed relationships between system affiliation and survival. Proportional hazards analyses indicate that system affiliation with investor-owned systems significantly reduces survival probabilities of rural hospitals. Affiliation with not-for-profit systems or system affiliation under contract management arrangements does not affect survival probabilities of rural hospitals. These general findings are moderated by the effects of hospital ownership and size at the time of affiliation. Finally, study findings indicated that systematic selection by poor performing rural hospitals into investor-owned systems has occurred in the post-PPS era. No evidence of selection into not-for-profit systems was discovered.

Economic evaluations of gastric and pancreatic cancer

The total cost of cancer care in the US is about $146 billion, of which pancreatic cancer comprises $2.6 billion (1.8% of the total) and gastric cancer comprises $1.8 billion (1.3%). We have reviewed published studies presenting economic analysis of treatment or follow-up for patients with pancreatic or gastric cancer. Relatively few studies report on economic evaluations of pancreatic cancer care. There are also few economic studies for gastric cancer, although we identified three cost-effectiveness analyses. In general, economic analyses in these areas are relatively unsophisticated, relying on charge data or simple multipliers (e.g., average cost per day in the hospital multiplied by days in the hospital), and are often limited to in-hospital costs (particularly studies for pancreatic cancer). A wide range of costs is included in these studies and a variety of methodologies for assigning costs are used, making comparisons between studies difficult. Future health economics research in this area should evaluate the costs and effectiveness of alternative practice patterns for gastric and pancreatic cancer; conduct additional cost-effectiveness analyses of chemotherapeutic interventions; consider quality of life, survival, stage at diagnosis, patient-borne costs, and complications of therapy; and, take advantage of administrative data from large populations.

Treatment patterns for otitis externa

BACKGROUND

Although otitis externa is a common and painful infection of the outer ear canal, there is little specific information available regarding current treatment patterns in the United States. We wanted to examine treatment patterns for otitis externa.

METHODS

Data were analyzed from the 1993 National Ambulatory Medical Care Survey (NAMCS) and the 1993 National Hospital Ambulatory Medical Care Survey (NHAMCS) for adults and children treated for otitis externa. Data analyses included the reasons for physician visits, concomitant diagnoses, types of physicians seen, sources of payment, medical procedures administered, drugs prescribed, and patient disposition following a physician visit.

RESULTS

Study results suggested that treatment patterns differ substantially for adults and children, as well as by physician specialty. Although otitis externa is frequently painful, few cases are classified as severe, and the data indicated that less than 20 percent of patients have concomitant diagnoses treatable by medication. Nevertheless, 40 percent of patients received both topical and systemic medication, and many of the oral antibiotics prescribed are not active against Staphylococcus aureus or Pseudomonas aeruginosa, the most common bacterial pathogens in otitis externa.

CONCLUSIONS

Appropriate treatment of localized otitis externa with topical antibiotics should eliminate the need for systemic medications. Addition of systemic medications can unnecessarily increase treatment costs and the likelihood of side effects, and could reduce the likelihood of patient compliance.

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy

OBJECTIVE

To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients.

BACKGROUND

Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs).

METHODS

We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years.

RESULTS AND CONCLUSIONS

The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.

The impact of candidemia on length of hospital stay, outcome, and overall cost of illness

Although numerous studies have examined trends in nosocomial fungal infections, few have specifically addressed the cost of care associated with candidemia. This study analyzes the direct medical costs associated with treating candidemia in the United States. The study design was a cost-of-illness analysis estimating the average cost of candidemia for a single episode of care. Data were obtained from three sources: the 1993 Healthcare Cost and Utilization Project of the Agency for Health Care Policy and Research, the relevant literature, and a clinical expert in systemic fungal infections. The estimated cost (1997 U.S.$) of an episode of care for candidemia is $34,123 per Medicare patient and $44,536 per private insurance patient. The major cost associated with candidemia is that of an increased hospital stay. The estimated cost of care for candidemia may change in the future because of the use of more expensive antifungal treatments with improved safety and efficacy profiles.

Health and economic outcomes modeling practices: a suggested framework

In the field of outcomes research, modeling is increasingly being used to assess costs and outcomes associated with healthcare interventions. However, there is little standardization with regard to modeling practices, and the quality and usefulness of economic and health outcomes models may vary. We propose the following set of recommendations for good modeling practices to be used in both the development and review of models. These recommendations are divided into three sections: criteria to be addressed before model development or initial review; criteria used during model development or evaluation; and criteria used following model development. These recommendations also include examples regarding different modeling techniques and practices as well as a checklist (see appendix) to assess model correspondence with the recommendations. We hope that the use of good practice recommendations for modeling will not only improve the development and review of models but also lead to greater acceptance of this methodology.

A pharmacoeconomic analysis of rimexolone for the treatment of ophthalmic inflammatory conditions

Topical steroids are the standard first-line therapy for treating ophthalmic inflammatory conditions. However, potent ophthalmic steroids can lead to an elevation of intraocular pressure (IOP), which can result in greater medical resource utilization and increased costs. We have developed a decision analysis model from a societal perspective to evaluate the costs and consequences of the treatment of ophthalmic inflammatory conditions with two potent topical steroids: prednisolone and rimexolone. Data for the model are based on information from clinical trials, national data-bases, published literature, and responses by ophthalmologists to a questionnaire on treatment patterns for elevated IOP. Three steroid-responsive conditions are examined separately with the model: uveitis; postoperative inflammation following cataract surgery; and other ophthalmic inflammatory conditions (blepharitis, episcleritis, postoperative refractive surgery, and corneal transplant). The model evaluates patients with acute conditions versus those with chronic conditions and those with mild to moderate elevation of IOP versus those with severe elevation of IOP. Although the unit cost of rimexolone is higher than that of prednisolone, use of rimexolone leads to cost savings because the incidence of elevated IOP is decreased. If rimexolone is used instead of prednisolone for the treatment of ophthalmic inflammatory conditions, the estimated cost saved (at 1995 AWP prices) is approximately $10 million across the entire US population. The savings across the health maintenance organization population on an annualized basis is approximately $3.9 million. Even if rimexolone were priced higher than current market charges (at 130% to 150% of the AWP of prednisolone), cost savings ranging from the $2.9 million to $720,000 would accrue with use of rimexolone compared with prednisolone. However if, rimexolone were priced at 160% of the AWP of prednisolone, its use would incur an additional cost of $300,000. The primary medical resource utilized in treating elevated IOP in ophthalmic inflammatory conditions is physician visits. Medications are responsible for only one-fifth to one-third of the total cost of treating elevated IOP. This analysis indicates that rimexolone is associated with decreased medical resource utilization and cost savings to the entire healthcare system.

A model of the cost-effectiveness of directly observed therapy for treatment of tuberculosis

A hypothetical cohort of 25,000 TB patients and their contacts were followed for a 10-year period; rates of treatment default, infectiousness following partial treatment, relapse, hospitalization, and development of drug-resistant TB were included. The average cost per case cured was $16,846 with 15% of patients starting DOT, $17,323 with 100% starting DOT, and $20,106 with none starting DOT. The incremental cost per additional case cured was $24,064 when all patients, started treatment on DOT, indicating that outpatient DOT provides a cost-effective method of improving health outcomes for TB patients and their contacts while controlling direct costs.

The economic and clinical efficiency of point-of-care testing for critically ill patients: a decision-analysis model

Our study objective was to assess economic and clinical outcomes of use of a point-of-care (POC) blood analysis device for postoperative coronary artery bypass graft (CABG) patients. A decision analytic model was developed for patients with high expected use of blood analysis, high potential benefit from rapid turn around time of results, a large annual volume of patients, and substantial expense associated with surgery. Published literature and clinical experts provided incidence, outcome, and cost estimates associated with four clinical scenarios potentially influenced by POC testing (ventricular arrhythmias, cardiac arrest, severe postoperative bleeding, and iatrogenic anemia). We found that changes in clinical outcomes were predominantly dependent on comparative turn around time or CABG patient volume. The positive clinical impact of using POC testing was consistently associated with a positive economic impact. POC blood gas analysis may be associated with decreased incidence of adverse clinical events or earlier detection of such events, resulting in significant cost savings. This study also supports previous findings that the costs of STAT blood analysis are more personnel-related than equipment-related.

Cost-effectiveness of thrombolytic therapy for acute myocardial infarction

OBJECTIVE

To estimate the cost-effectiveness of thrombolytic therapy versus no thrombolytic therapy for patients following acute myocardial infarction, focusing on the impact of time to treatment on outcome.

METHODS

A decision model was developed to assess the benefits, risks, and costs associated with thrombolytic therapy for treatment of acute myocardial infarction compared with standard nonthrombolytic therapy. The model used pooled data from a recent study of nine large randomized, controlled clinical trials and 12-month outcome data from a recently published meta-analysis of thrombolytic therapy trial data. Outcomes were expressed in terms of survival to hospital discharge and survival to 1 year after discharge. The risks of treatment that led to death, morbidity, or added costs were estimated. The model determined excess and marginal costs per death averted to hospital discharge and at 1 year. Results were also estimated in terms of cost per year of life saved. Sensitivity analyses included variations in time to treatment and drug cost.

RESULTS

The marginal cost of thrombolytic therapy per death averted at 1 year was $222,344, or $14,438 per year of life saved. For patients treated within 6 hours of acute myocardial infarction, the marginal cost per death averted was $181,536 at 1 year, or $11,788 per year of life saved.

CONCLUSIONS

Thrombolytic therapy is significantly more cost-effective than many other cardiovascular interventions and compares favorably with other forms of medical therapy. Results suggest that shortening the time to treatment has a critical impact on the cost-effectiveness of thrombolytic therapy.

Cost analysis of once-daily ISMN versus twice-daily ISMN or transdermal patch for nitrate prophylaxis

OBJECTIVE

To compare the costs and outcomes of treating exercise-induced angina with once- or twice-daily isosorbide mononitrate (ISMN) or transdermal patch.

METHOD

A decision-analytic model was designed based on published literature showing compliance and increasing symptoms and estimates from physicians on treatment patterns and worsening symptoms.

RESULTS

Data show that patients are more compliant with once-daily ISMN (Imdur, Astra Hässle, Mölndal, Sweden) and patch regimens than with twice-daily dose. Based upon the assumption that more compliant patients are better controlled, the model found that fewer medical care resources were consumed by patients treated with the once-daily and the patch regimens. The unit cost of the twice-daily ISMN regimen is 40% of the unit cost of the once-daily. Annual costs of treating an exercise-induced angina patient are 248 pounds for Imdur compared to 250 pounds for the twice-daily ISMN and 299 pounds for the transdermal patch.

CONCLUSION

Unit prices alone are not good indicators for estimating medical management costs.

Cost of refractory epilepsy in adults in the USA

A cost of illness of refractory epilepsy was developed based on estimates supplied by an expert panel of physicians and a review of the current literature. The basic elements of model can be divided into two main components: direct and indirect costs. Direct costs include the medical resource utilization patterns associated with epilepsy care while the indirect costs represent lost productivity associated with the disease. The results of the analysis indicate that an estimated 24,578 incident cases of epilepsy incur a total of $318,582,669; while our prevalence estimates indicate that 335,167 individuals incur a total of $3,905,183,463, in a given year. Direct medical costs account for one-third of the total costs while indirect costs constitute the remaining two-thirds.

The short-term effects of merger on hospital operations

OBJECTIVE

The short-term effects of merger on three areas of hospital operations - scale of activity, personnel/staffing practices, and operating efficiency - is examined.

DATA SOURCES

Secondary data obtained from the AHA Annual Surveys (1980-1990) were applied to analyze 92 hospital mergers over the period 1982-1989.

STUDY DESIGN

The study employed a multiple time-series design involving a six-year longitudinal assessment of change in hospital operating characteristics before and after merger, and a parallel analysis of change in a randomly selected group of nonmerging hospitals.

DATA COLLECTION

Pooled, cross-sectional data files were constructed. Comparisons were evaluated using paired and two-sample t-tests.

PRINCIPAL FINDINGS

General merger effects occurred primarily in areas related to operating efficiency. Merger resulted in slowing rates of preexisting trends, rather than dramatic improvements in operating practices.

CONCLUSIONS

The short-term impact of merger was generally modest but differed by the conditions under which the merger occurred. Specifically, mergers occurring later in the study period and mergers between similarly sized hospitals displayed greater change in operating characteristics than those occurring earlier in the study period and those between hospitals of dissimilar size. Such differences are attributed respectively to increased competitive pressures after PPS and to greater opportunities for consolidation and efficiencies in mergers involving similarly sized hospitals.

Effect of smoking characteristics on cognitive dissonance in current and former smokers

The effect of smoking characteristics on the development of cognitive dissonance in current and former smokers is examined. Smoking characteristics (number of cigarettes per day, number of years smoked, and years since quitting) and health beliefs were obtained from over 9,000 respondents to the 1986 Adult Use of Tobacco Survey. Overall, current smokers exhibited more cognitive dissonance involving smoking-related beliefs than did former smokers. Logistic regression analysis indicated that heavier current smokers (those smoking > or = 20 cigarettes per day) were more likely to exhibit cognitive dissonance over smoking-related health beliefs than were lighter smokers. In contrast, number of cigarettes consumed per day had only minor effects on former smokers' beliefs; former smokers who had smoked for more years (> or = 17), or who had quite recently (within the last 8 years), were more likely to showed greater dissonance than former smokers without these characteristics. The factors underlying these results and their implications for smoking cessation programs are discussed.

Differences in former smokers' beliefs and health status following smoking cessation

Many studies have examined changes in former smokers' disease risk after smoking cessation. Little is known, however, about differences in the health beliefs and self-reported health characteristics of former smokers in the years following cessation. We examine these differences in former smokers, using data from the 1990 National Health Interview Survey. Current smokers were less likely than people who had never smoked to perceive both smoking and nonsmoking disease risk factors as dangerous. Recent former smokers held beliefs similar to those of respondents who had never smoked. Former smokers who had quit for five years or more tended to believe in the effects of these risk factors even more than those who had never smoked. For self-perceived health characteristics, current smokers generally indicated worse health than did lifelong non-smokers. Former smokers who had recently quit reported even worse health than current smokers. For certain health indicators, former smokers were more likely to indicate poor health than were current smokers even a decade or more following smoking cessation. These results, based on health beliefs and health characteristics, suggest that former smokers are a diverse group and should not be compared to other smoking-status groups without evaluation of the time interval since smoking cessation.

Patient adherence to prescribed potassium supplement therapy

We have investigated whether patient adherence ratios calculated from prescription refill data for potassium supplement medications differ depending on the type of supplement. By using automated pharmacy claims records from a large managed care organization, an index of adherence to prescribed therapy was calculated for each patient as a ratio of total days of drug supplied to the total number of days between prescription refills. The mean patient adherence to prescribed therapy ratios were compared among different potassium drug regimens. There were 2289 patients eligible for analysis; 65.9% were women, and the mean age was 57.6 years. The mean patient adherence ratio for one brand of extended-release tablet, K-DUR, was 0.81 (a majority of the patients were receiving 20 mEq/day). This was higher than the combined mean patient adherence ratio for all other supplements (0.73); the combined mean ratio for all other extended-release tablets (0.74); the combined mean ratio for all other tablets and capsules (0.74); the combined mean ratio for liquids (0.50); the combined mean ratio for liquids and powders (0.63); and equivalent to the ratio for another extended tablet, Micro-K (0.82). Regression analysis showed that increased patient adherence was seen among patients taking K-DUR tablets as compared with those taking other potassium supplements. Increased adherence among patients taking K-DUR remained statistically significant after controlling for number of prescriptions filled, dose, age, sex, and health plan location. Pharmacy claims data can be used effectively to measure patient adherence with potassium supplement therapy. Future research should relate patient adherence ratios to clinical outcomes.

Patterns of absolute risk of lung cancer mortality in former smokers

BACKGROUND

It is well known that the relative risk (RR) of lung cancer mortality decreases following smoking cessation compared with the risk in persons who continue to smoke. However, changes in the absolute risk of lung cancer death following smoking cessation are not well documented. Further, few studies have examined the effect of age at smoking cessation on subsequent lung cancer death risk.

PURPOSE

The purpose of this study was to examine and compare absolute and relative lung cancer death risks in former smokers as a function of age at cessation.

METHODS

Using the American Cancer Society's Cancer Prevention Study II, a prospective cohort study with 6 years of follow-up, we modeled absolute risk of lung cancer mortality in individuals who had never smoked and in current and former smokers. The model was fit with the use of person-years logistic regression analysis.

RESULTS

Similar patterns of absolute risk of lung cancer death by age were found for all ages of smoking cessation up to the mid-60s. Lower lung cancer death risk was observed for those quitting earlier in life, and the risk for all former smokers was significantly lower than that for current smokers. For those quitting between ages 30 and 49, lung cancer death risk rose gradually with age at a rate slightly greater than that for those who had never smoked. Lung cancer death risk for former smokers quitting between ages 50 and 64 leveled off near the risk attained at the time of quitting until around age 75, when it rose sharply. At age 75, the RR for former smokers compared with current smokers was approximately 45% for those quitting in their early 60s, approximately 20% for those quitting in their early 50s, and less than 10% for those quitting in their 30s. For those who had never smoked, the RR at age 75 is less than 5%.

CONCLUSIONS

In terms of reduced risk of lung cancer mortality, smoking cessation is beneficial at any age, with much greater benefits accruing to those quitting at younger ages. Unlike previous research, which has primarily examined the effects of cessation as a function of years since quitting, our results demonstrate that age at cessation has a major impact on subsequent lung cancer risks.

IMPLICATIONS

Smokers of all ages should be encouraged to quit because cessation at any age decreases lung cancer risk relative to that of current smokers.

Leadership instability in hospitals: the influence of Board-CEO relations and organizational growth and decline

This study tested whether leadership instability--a systemic pattern of frequent succession in the top management position of an organization--was associated with sociopolitical structures that define the relationship between the board and chief executive officer (CEO), controlling for temporal patterns of the organizational life-cycle stage. In organizations that are not profit maximizing and subject to considerable uncertainty, such governance properties were hypothesized to affect leadership instability independent of organizational growth or decline. Results of regression analyses demonstrate strong main effects of board-CEO relations, net of the impact of organizational life cycle, on leadership instability.

Motivations for smoking cessation: a comparison of successful quitters and failures

To foster successful smoking cessation, public health professionals need to understand better the reasons why smokers quit smoking. Although researchers have studied smokers' characteristics that may predict smoking cessation, few studies have examined the relationships between reasons stated for quitting and successful smoking cessation. We examined six reasons for smoking cessation and their association with successfully quitting among approximately 7,700 current and former smokers who participated in the 1986 Adult Use of Tobacco Survey (AUTS). Using logistic regression analysis, we found that successful cessation was associated with having personal concerns regarding the health effects of smoking and with wanting to set a good example for children. In contrast, concerns about the cost of smoking, the effect of smoking on others, and pressure from friends and family to quit were associated with decreased likelihoods of cessation. Furthermore, the relative importance of a reason (somewhat important vs. very important) also influenced the association of that reason with smoking cessation.

Modulation of a human immunosuppressive lymphokine by monosaccharides

Soluble suppressor factor (SSF) is a recently purified human lymphokine produced by peripheral blood lymphocytes (PBL) in serum-free medium as a likely consequence of an autologous mixed lymphocyte reaction. Immunoregulatory actions of SSF include suppression of: polyclonal B cell activation, proliferative responses of normal PBL, and natural killer (NK) and antibody-dependent cellular cytotoxicity. We examined the ability of the monosaccharides fucose (Fuc), galactose (Gal), glucose (Glc), and mannose (Man) to reverse SSF-mediated suppression of NK activity. Fuc and Gal can partially or completely reverse SSF-mediated suppression at four effector:target cell ratios. Man and Glc were unable to significantly reverse SSF-mediated suppression. Fuc or Gal was added to PBL at various times after addition of SSF. SSF-mediated suppression of NK cytotoxicity becomes irreversible with respect to these monosaccharides during the first 24 hr of PBL exposure to SSF. To explore the mechanism behind this block of SSF-mediated suppression. Fuc or Gal (50 mM) was cultured with PBL for 24 hr before addition of SSF, or with SSF for 24 hr before addition to PBL. Our experiments indicate that SSF is directly interacting with these monosaccharides, and may function by recognizing specific sugar moieties on the surface of effector cells.

Human nonspecific suppressive lymphokines

Since the term "lymphokine" first appeared in print over 20 years ago, a tremendous number of these soluble mediators of the immune system have been described. Within the past few years, many human nonspecific suppressive lymphokines have been identified. This review discusses the historical basis of immunologic suppression and suppressor factors. Later reports describing suppressive human lymphokines are then grouped into four categories: primarily stimulatory lymphokines that also mediate certain suppressive activities, suppressive lymphokines produced during altered states of immunity, suppressive lymphokines produced by exogenously stimulated lymphocytes, and suppressive lymphokines produced by unstimulated lymphocytes. Recent work I have been involved in focusing on the human suppressive lymphokine soluble suppressor factor (SSF) is also discussed.