Gastroesophageal reflux disease.

The data indicate that gastroenterologists have higher (P < .05) utilization, covered charges, and prescription drug utilization per PTE than FPs/GPs with regard to patients with lowest-severity GERD. The data show that patients treated by an FP/GP have significantly lower PTE duration when compared with patients treated by gastroenterologists. Average overall charges for FPs/GPs are also significantly lower than average overall charges for gastroenterologists. Additionally, average prescription drug charges per PTE are lower for FPs/GPs than for gastroenterologists. An important consideration is the variation of practice patterns in the treatment of GERD. This analysis is not based on a controlled study; therefore, adjustments for patients demographic and geographic factors are necessary in order to provide further reliable analysis. Additional research in this area is worthwhile and may include a controlled comparison of practice patterns among PCPs and specialists in relation to the quality of care and cost effectiveness of treatments prescribed for GERD.

Upper respiratory tract infections.

The routine, easiest-to-treat URI PTEs utilized 1.1 office visits during the course of a PTE. This patient group also received 0.05 tests, 0.66 laboratory and pathology services, and 0.05 medical/surgical procedures during the course of a PTE averaging 9.6 days in length. The major cost driver for URI PTEs was physician visits. Approximately 62% of URI PTEs produced a claim for prescription drug therapy. Overall, URI patients were treated with 1.3 prescriptions per PTE. Thirty-two percent of all PTEs received one-drug group and 17.5% received two-drug group treatments. Amoxicillin was the most commonly used drug for these patients.

Use of diagnostic cluster methodology for therapeutic costing and drug surveillance of HMG-CoA reductase-inhibitor therapy.

Diagnostic cluster methodology groups patients having similar medical conditions according to their International Classification of Diseases, 9th Revision codes. Episodes of care related to the diagnostic cluster can then be tracked from the claims data to determine the total charges associated with patient management. A retrospective claims analysis using an episode registry database was conducted to determine the 1-year (July 1, 1995, to June 30, 1996) covered charge for statin therapy, the overall cost of treating related cardiovascular (CV) disease, and the cost impact of coadministration of drugs that potentially compete for hepatic metabolism. The three statin treatment groups (lovastatin, pravastatin, and simvastatin) were similar with respect to age, gender, mean number of prescription refills, rate of refill compliance, and prevalence of the coadministration of potentially interacting agents. Before adjustment for severity of illness, there were no significant differences between groups in prescription drugs/services (statin Rx/Svc) or total CV charges. After adjustment for severity of illness, the pravastatin group had the lowest statin Rx/Svc and total CV charges. Within the group with the greatest severity of illness, statin Rx/Svc charges were significantly lower with pravastatin than with lovastatin and simvastatin. The statin Rx/Svc charges were not significantly different between lovastatin and simvastatin. Coadministration of a potentially interacting agent significantly increased both the statin Rx/Svc and total CV charges within the simvastatin-treated group but did not significantly influence costs in the lovastatin- or pravastatin-treated groups. The estimates of direct costs derived from this analysis are consistent with findings in the published literature and demonstrate that pravastatin has cost advantages compared with lovastatin and simvastatin. Diagnostic cluster methodology also generated valuable information regarding drug surveillance and the health care cost impact of potential drug-drug interactions with selected statins.

Low back pain.

An SOI-I low back pain PTE utilized 2.5 office visits with an adult medicine physician compared with 3.7 office visits with an orthopedic surgeon. Adult medicine physicians performed 1.1 tests and administered 4.6 prescriptions during an SOI-I low back pain PTE. Office visits, tests, and prescriptions were the major cost drivers for low back pain PTEs. Of all low back pain PTEs, 19% received one-drug group, and 17.2% received two-drug group treatments. Nonsteroidal anti-inflammatory drugs and central muscle relaxants were the most commonly used medication therapies for these patients.

Urinary tract infections.

Women between the ages of 18 years and 64 years with the easiest-to-treat UTIs average 1.07 office visits, 2.36 prescriptions, and 2.34 laboratory and pathology services per PTE. Laboratory services were performed an average of 2.27 times per PTE on an outpatient basis. This patient group did not receive a significant amount of hospital admissions or professional inpatient services. Approximately 71% of all PTEs were treated with pharmaceutical therapy. Of the overall charges for UTIs, 31% were for prescription drug therapy. Of those patients treated with a single drug group, almost 33% were treated with trimethoprim/sulfamethoxazole and 13.2% were treated with a fluoroquinolone. Considering the potential cost savings of encouraging adherence to clinical prescribing guidelines, further investigation of physician prescribing patterns for uncomplicated UTIs may prove valuable to health plans.

Hemorrhoids.

The patients with routine, easiest-to-treat hemorrhoids average 1.25 office visits, 0.80 prescriptions, and 1.38 medical/surgical procedures during the course of a year. About 63.9% of all PTEs were treated without the use of prescription drugs. This patient group did not receive any hospital admissions or professional inpatient services. Hemorrhoid surgery was performed at an average rate of 1.37 times per PTE on an out-patient basis. Seventy-two percent of the overall medical charges for hemorrhoid treatment are direct surgical charges. Of the PTEs treated with a single drug group, only 1.5% are treated with a prescription laxative. However, the use of OTC stool softeners and laxatives were not measured in this analysis. Thus, an exact measurement of cost savings associated with appropriate use of softeners/laxatives for the prevention of recurrent hemorrhoids could not be determined. Considering the potential cost savings of using laxatives for prevention of hemorrhoids, further investigation of the prescribing patterns of this specialty may prove useful.

Glaucoma.

The routine, easiest-to-treat adult patients with glaucoma utilize 1.80 office visits, 3.34 prescriptions, and 2.02 medical/surgical procedures during the course of a year. Based on data from the PTE-Registry database, this patient group did not receive any hospital admissions or professional inpatient services. Eye surgery was performed at an average rate of 0.08 times per PTE. About 53.5% of all PTEs were treated without the use of prescription drugs. When a drug was prescribed, beta blockers were used most often. In fact, 74.1% of all PTEs treated with a single drug group used a beta blocker.

New payments and incentives in contact capitation: an orthopedics case study.

The purpose of this article is to present a model for equitable distribution of orthopedic contact capitation payments. This model accounts for services covered, patient severity of illness, patient age, and condition prevalence.

Pediatric otitis media.

The pediatric patients with routine, easiest-to-treat otitis media utilize 2.1 office visits during the course of a PTE. This patient group also received 0.13 tests, 0.14 laboratory and pathology services, and 0.05 medical/surgical procedures during the course of a PTE. Though 29.2% of these patients did not produce a claim for prescription drug therapy, this patient group received at least 1.53 prescriptions per PTEs. One prescription drug group was used in 39.8% of all PTEs. Of the PTEs treated with a single drug group, at least 56.4% were treated with amoxicillin. Two prescription drug groups were used in 18.1% of the PTEs. The prescribing patterns of physicians using two drug groups demonstrate a wide variety of switching patterns, some of which may have cost-of-care implications. Though surgical procedures are seldom utilized in SOI-1, approximately one-half of SOI-2 PTEs undergo some type of surgical procedure. The most common surgical procedure was myringotomy with the PE-TM tubes, which represents 82% of procedures performed on SOI-2 patients. The major cost drivers in the treatment of otitis media are clinical visits and antimicrobial drugs.

Patient care management programs: maximizing efficiency through the use of prevalence rates.

Providers are assuming more risk for patient management than ever before. This has led to more interest in managing patients with high-cost, chronic illnesses. In the following article, the authors discuss how accurate chronic disease prevalence rates can be used to better focus care management efforts, leading to a successful, cost-efficient program.

Nonmigraine headaches.

The easiest-to-treat nonmigraine headaches for the 18-to-64 year old population have an average duration of 60 days. The most common diagnostic imaging test used is the computed tomography scan performed on the head or brain. Two out of 1,000 patients have a hospital admission. About 43% of the PTEs are treated without prescription. When a single prescription drug group is used, 56.7% of the prescriptions are for pain relief drugs. Nonsteroidal anti-inflammatory drugs are the most prescribed single drug group for this condition.