False positive results: a challenge for psychiatric screening in primary care.

OBJECTIVE: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. METHOD: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. RESULTS: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. CONCLUSIONS: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.

Investment in prolonged thromboprophylaxis with dalteparin improves clinical outcomes after hip replacement.

Clinical guidelines recommend the use of extended out-of-hospital thromboprophylaxis in patients who have had major arthroplasty. However, the cost-effectiveness of prolonging pharmacological thromboprophylaxis into the out-of-hospital phase following hip replacement surgery remains the subject of considerable debate. This debate centers on the clinical relevance of the 'surrogate' venographic endpoints that have been used in most clinical trials and used to generate some of the cost analyses of thromboprophylaxis. The objective of this study was to estimate, from the payer perspective, the direct medical costs of prolonging the duration of thromboprophylaxis with dalteparin from 1 week to 28-35 days in patients undergoing hip replacement, and to compare these to the costs associated with using 'standard' in-hospital thromboprophylaxis with low-molecular-weight heparin (LMWH) or warfarin. To derive 'best' estimates for rates of clinically and economically relevant thromboembolism associated with hip replacement surgery (i.e. those that would in reality incur management costs), we used data on the prevalence of both symptomatic and asymptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE). These estimates were used in conjunction with diagnostic-related groups (DRG) reimbursement rates and a dalteparin cost model, which assumed home-based self-administration for prolonged thromboprophylaxis, to calculate overall direct medical costs of prolonged vs. in-hospital thromboprophylaxis. The management costs of the strategies evaluated were, to the nearest 1000 Euros: 465 000 Euros for in-hospital prophylaxis with LMWH; 339 000 Euros for in-hospital prophylaxis with warfarin; and 368 000 Euros for prolonged prophylaxis with dalteparin. For every 1000 patients treated, prolonging thromboprophylaxis with dalteparin from 1 to 4-5 weeks will avoid 30 clinical DVTs and 18 PEs at a saving of 2000 Euros per clinical event. Compared with in-hospital warfarin, prolonged thromboprophylaxis with dalteparin will avoid 28 DVTs and four PEs at an incremental cost-effectiveness ratio of 900 Euros per clinical event avoided. We consider that investment in prolonged thromboprophylaxis with dalteparin is justified for the improvement in clinical outcomes produced.

Two approaches to comparing hospital charges between cadaveric renal transplant patients who received orthoclone OKT 3 sterile solution or Atgam sterile solution for induction therapy.

The objectives of this study were: (1) to compare total hospital charges for a sample of cadaveric renal transplant patients categorized according to the type of induction therapy used (Orthoclone OKT3 Sterile Solution or Atgam Sterile Solution); (2) to compare specific charge categories between the two groups; and (3) to examine the relationship between charges and a set of independent variables. A retrospective review was conducted of hospital charges associated with a sample of renal transplant patients. The overall sample for this study comprised 510 patient discharges from 22 hospitals in the United States. Comparisons between the OKT3 and Atgam groups were made for total and specific charge categories using two different approaches to help control variations in charges that were not related to the type of induction therapy used. The first approach consisted of t test or chi-square comparisons between the groups for subsets of observations that had been identified in a stepwise fashion. These judgment samples were defined to remove sources of variation in charges other than those resulting from the type of induction therapy selected. The second approach used multiple linear regression analysis to help statistically control variation in charges from other sources. The results showed that higher drug charges in the Atgam group were offset by lower charges in other categories (P < 0.05). These findings suggest that hospital formulary committees should consider all relevant costs, not just drug acquisition costs, when selecting products. However, further investigation is warranted to explore differences in charges due to: (1) between-hospital variation; (2) patients' severity of illness before receiving induction therapy; and (3) differences in side-effect profiles for the two induction therapies.

Comparison of length of hospital stay for patients with known or suspected methicillin-resistant Staphylococcus species infections treated with linezolid or vancomycin: a randomized, multicenter trial.

STUDY OBJECTIVE: To compare hospital length of stay (LOS), weekly discharges, and days of antibiotic treatment with linezolid (intravenous with oral follow-up) and vancomycin (intravenous only). DESIGN: Multinational, randomized, phase III trial. SETTINGS: Hospitals in North America, Latin America, and Europe. PATIENTS: Four hundred sixty hospitalized patients with infections of known or suspected methicillin-resistant Staphylococcus species. INTERVENTION: Administration of linezolid or vancomycin. MEASUREMENTS AND MAIN RESULTS: For linezolid recipients, median LOS was 5 and 8 days shorter (p=0.05 and 0.003) in the complicated skin and soft tissue infection intent-to-treat (230 patients) and clinically evaluable (144) samples, and slightly but not significantly shorter in the overall intent-to-treat (460) and clinically evaluable (254) samples. In all samples, linezolid recipients had more discharges in the first week of treatment and fewer days of intravenous therapy than vancomycin recipients. CONCLUSION: Our results support linezolid's ability to reduce medical resource use.

Economic evaluation of systemic treatments for cytomegalovirus retinitis in patients with AIDS.

OBJECTIVE: To determine the cost of using systemic therapy to treat newly diagnosed cytomegalovirus (CMV) retinitis in persons with AIDS. DESIGN: Incidence-based simulation model of CMV treatment from a government payer perspective. SETTING: Swiss healthcare system. PATIENTS AND PARTICIPANTS: Patients with AIDS and newly diagnosed CMV retinitis. INTERVENTIONS: Patients were assigned to 1 of 4 treatment regimens for induction and maintenance therapy: (i) intravenous (IV) cidofovir induction and maintenance (cidofovir IV/IV); (ii) IV foscarnet induction and maintenance (foscarnet IV/IV); (iii) IV ganciclovir induction and maintenance (ganciclovir IV/IV); and (iv) IV ganciclovir induction and oral (PO) ganciclovir maintenance (ganciclovir IV/PO). Following a second relapse, patients were assigned to one of the other regimens. MAIN OUTCOME MEASURES: Time to first and subsequent progression, duration of maintenance treatment and direct medical expenditures [1998 Swiss francs (SwF)] . RESULTS: The median time to first progression was longest for cidofovir IV/IV, followed by foscarnet IV/IV, ganciclovir IV/IV and ganciclovir IV/PO. Mean survival was 13 months and mean costs for this period in the base case were lowest in those initially treated with cidofovir (SwF146,742), followed by initial treatment with foscarnet IV/IV (SwF194,809), ganciclovir IV/PO (SwF195,190) and ganciclovir IV/IV (SwF243,964). Costs were most sensitive to changes in efficacy estimates. CONCLUSIONS: Of the regimens studied, initiation of treatment with systemic cidofovir appears least costly over a 13-month period.

Commercial drug compendium information: a First World/Third World comparison.

The purpose of this study was to determine what differences exist in the content of commercial drug compendium monographs available in First World and Third World countries. A content model representing First World information was developed from monographs contained in the Physicians' Desk Reference, ABPI Data Sheet Compendium, and the Rote Liste. The content of the three First World compendia was found to be variable, with the Physicians' Desk Reference consistently more comprehensive than either the ABPI or Rote Liste. This result suggests that there is a lack of agreement among industrialized countries regarding what amount of information is necessary or appropriate for inclusion in a commercial drug compendium. A sample of 58 monographs was selected from four Third World compendia and evaluated in terms of comprehensiveness and accuracy. These monographs represented five commonly prescribed drugs from the World Health Organization's Essential Drugs List. The monographs were found to be less comprehensive than any of the three monographs contained in the First World compendia. Approximately 5 percent of the information contained in the sampled monographs was determined to be inaccurate. The sampled monographs for drugs supplied by multi-national pharmaceutical firms were found to contain the same amount of information as those for drugs supplied by domestic firms.

The importance of considering non-monetary costs and benefits in selecting pharmacologic interventions in mental health.

The continuing increase in health care costs has focused more attention on the value associated with a therapeutic intervention in addition to its clinical efficacy and safety. Although safety and efficacy are important, the effectiveness of an intervention in practice is the yardstick for assessing a therapy's societal benefit. In measuring effectiveness outcomes, all the relevant costs and benefits must be considered, including those that extend beyond the direct costs of care. Patient quality of life and, related to it, work productivity are two additional outcomes worthy of consideration. This article presents a discussion of several economic approaches to measuring indirect costs, the relationship between indirect costs and quality of life, and the relevance of such evaluations in the area of mental health, and offers recommendations for researchers.

Incorporating individualized quality of life measures in the evaluation of pharmacy services: the IN*COMPASS framework.

Quality of life is a fascinating field to researchers and practitioners alike. To some researchers, quality of life is of interest because it offers untold challenges in constructing instruments and capturing data necessary to answer key questions about health, disease, and treatment. For such researchers, quality of life is about statistical relationships among questions and about using questions to define the physical, social, and emotional domains of health. To other researchers, this field is about finding practical applications in policy and treatment decision making for the information provided by quality of life assessments. To these researchers, the focus of quality of life is on ways to apply knowledge of quality of life differences between groups with and without specific diseases or ways to use knowledge about how treatments affect the quality of life of various patient populations. To practitioners, quality of life is about treatment outcomes that impact individual patients' daily lives. It is the practitioner that Funderburk, Pleil, and Pathak are considering in their paper in this issue of Pharmacy Practice Management Quarterly. These authors give several important messages to practitioners seeking to serve their patients by incorporating quality of life into their practices. The key message in the paper is that to better understand and determine the impact of treatment on a patient's quality of life, it is critical to start with a baseline or reference point relevant to that patient. From that baseline or reference point, treatment decisions can be made and progress, in quality of life terms, can be evaluated. Critical questions in their framework, which is called the IN*COMPASS (Individualized Client Oriented Method for Preferred Alleviation of Sickness States) Approach, are "How are you now?" and "How would you like to be?" The authors do not endorse particular quality of life tools in their approach; rather they prescribe certain critical questions that must be answered if information captured by any quality of life tool is to be useful at the patient level. Readers should not be put off by the fancy acronym used in this paper; nor must readers be keen students of quality of life to appreciate its message. The IN*COMPASS approach is fundamental to good patient care and can be applied by practitioners with any level of understanding of and appreciation for quality of life assessments.