Osteoporotic fractures: a systematic review of U.S. healthcare costs and resource utilization.

Osteoporotic fractures are costly in terms of both the dollar amount and healthcare utilization. The objective of this review was to systematically synthesize published evidence regarding direct costs associated with the treatment of osteoporosis-related fractures in the U.S. We conducted a systematic literature review of published studies that used claims databases and economic studies reporting costs associated with osteoporosis-related fractures in the U.S. Studies published between 1990 and 2011 were systematically searched in PubMed (primary source), Ovid HealthSTAR, EMBASE and the websites of large agencies. Data concerning study design, patient population and cost components assessed were extracted with qualitative assessment of study methods, limitations and conclusions. Cost assessment included direct medical and hospitalization (inpatient) costs. The cost differences by age and gender were examined. Of the 33 included studies, 26 reported an estimated total medical cost and hospital resource use associated with osteoporotic fractures. These studies indicated that, in the year following a fracture, medical and hospitalization costs were 1.6-6.2 higher than pre-fracture costs and 2.2-3.5 times higher than those for matched controls. Analysis of the hospitalization costs by osteoporotic fracture type resulted in hip fractures identified as the most expensive fracture type (unit cost range $US 8358-32195), while wrist and forearm fractures were the least expensive (unit cost range $US 1885-12136). Although incremental fracture costs were generally lower in the elderly than in the younger population, total costs were highest for the older (≥65 years of age) population. Total healthcare costs for fractures were highest for the older female population, but unit fracture costs in women were not consistently found to be higher than for men. The qualitative assessment of the included studies demonstrated that the design and reporting of individual studies were of good quality. However, the findings of this review and comparisons across studies were limited by differences in methodologies used by the different studies to derive costs, the populations included in the studies used and the fracture assessment. Despite the variability in estimates, the literature indicates that osteoporosis-related fractures are associated with high total medical and hospitalization costs in the U.S. The variability in the cost estimates highlights the importance of comparing the methodologies and the types of costs used when choosing an appropriate unit cost for economic modelling.

A meta-analysis of osteoporotic fracture risk with medication nonadherence.

OBJECTIVES: Therapy for osteoporosis reduces the risk of fracture in clinical trials; real-world adherence to therapy is suboptimal and may reduce the effectiveness of intervention. The objective was to assess the fracture risk among patients nonadherent versus adherent to therapy for osteoporosis. METHODS: Medline, Embase, and CINAHL were searched for English-language publications of observational studies (January 1998-February 2009). Proceedings from two recent meetings of five relevant conferences were hand searched. Prospective and retrospective observational studies of patients with osteoporosis receiving bisphosphonates, parathyroid hormone, or selective estrogen receptor modulators denosumab were included. Studies were required to consider both fracture risk and adherence (compliance and/or persistence); any definition of adherence/fracture was acceptable. Data were analyzed using pooled comparisons of the odds and hazard ratios of fracture in noncompliance versus compliance and nonpersistence versus persistence. Sensitivity analyses were conducted to determine the effect of clinical heterogeneity on the results. RESULTS: Twenty-seven citations were identified, the majority of which were retrospective database analyses considering the effect of adherence to bisphosphonate therapy on fracture at any skeletal site. The absolute frequency of fracture ranged from 6% to 38% with noncompliance and from 5% to 19% with nonpersistence (104-159 weeks). Meta-analysis indicates that fracture risk increases by approximately 30% with noncompliance (odds ratio [95% confidence interval] 1.29 [1.22-1.38]; hazard ratio 1.28 [1.18-1.38]) and by 30% to 40% with nonpersistence (odds ratio 1.40 [1.29-1.52]; hazard ratio 1.32 [1.23-1.42]). CONCLUSIONS: Poor medication adherence is associated with a significantly increased risk of fracture versus optimal adherence. Improving medication adherence in patients with osteoporosis may lead to a greater reduction in fracture.

Cost burden of second fracture in the US health system.

OBJECTIVES: This retrospective claim-based study assessed 1-year medical costs associated with second fracture(s) for patients over 50 years old with an initial closed hip, clinical vertebral or non-hip non-vertebral (NHNV) fracture using 2002-2008 MarketScan® Commercial and Medicare Supplemental Databases. METHODS: Patients with incident fracture and ≥12-month pre-period and follow-up period from the incident fracture were extracted. Index date was the first subsequent fracture date for patients with subsequent fracture during the 12-month (cases); index dates for patients without subsequent fractures during the 12-month follow-up (controls) were randomly assigned based on the distribution of index dates of cases. Total costs were examined during the 12-month follow-up period using generalized linear models. A decomposition analysis of the incremental costs attributable to the second fracture was conducted to examine what proportion of the difference was due to different patient characteristics and what proportion was due to different model structures between cases and controls. RESULTS: For privately insured patients with hip, vertebral, or NHNV fracture, the 1-year second fracture rate was 8.0%, 5.1%, and 4.0%, and 1-year incremental costs were $47,351, $43,238, and $23,852, respectively; for Medicare patients, the corresponding rates and costs were 8.8%, 9.2%, and 8.2%, and $18,645, $19,702, and $19,697. Nationally projected annual cost of second fracture was $834 (95% confidence interval: $763-$914) million for patients with commercial insurance and $1.13 (95% confidence interval: $1.09-$1.17) billion for Medicare patients. CONCLUSIONS: The average cost of patients with subsequent fracture(s) was substantial. Effective management of first fractures may help reduce the long-term economic and clinical burden.

Direct healthcare costs of hip, vertebral, and non-hip, non-vertebral fractures.

Limited data exist regarding the cost of non-hip, non-vertebral (NHNV) fractures. Although NHNV fractures may be less expensive than hip and vertebral fractures, they have a higher incidence rate. The objective of this study was to quantify first-year healthcare costs of hip, vertebral, and NHNV fractures. This was a claims-based retrospective analysis using a case-control design among patients with commercial insurance and Medicare employer-based supplemental coverage. Patients were > or =50 years old with a closed hip, vertebral, or NHNV fracture between 7/1/2001 and 12/31/2004, and continuous enrollment 6 months prior to and 12 months after the index fracture. Adjusted mean first-year healthcare costs associated with these fractures were determined. Six cohorts were identified. Patients 50-64 years: NHNV (n=27,424), vertebral (n=3386) and hip (n=2423); patients > or =65 years: NHNV (n=40,960), vertebral (n=11,751) and hip (n=21,504). The ratio of NHNV to hip fractures was 11:1 in the 50-64 cohort and 2:1 in the > or =65 cohort. Adjusted mean first-year costs associated with hip, vertebral, and NHNV fractures were $26,545, $14,977, and $9183 for the 50-64 age cohort, and $15,196, $6701, and $6106 for patients > or =65 years. After taking prevalence rate into account, the proportion of the total fracture costs accounted for by NHNV, hip, and vertebral fractures were 66%, 21% and 13% for the 50-64 age cohort, and 36%, 52% and 12% for the > or =65 age cohort. Limitations included the exclusion of the uninsured and those covered by Medicaid or military-based insurance programs. The results of this study demonstrate that osteoporotic fractures are associated with significant costs. Although NHNV fractures have a lower per-patient cost than hip or vertebral fractures, their total first-year cost is greater for those 50-64 because of their higher prevalence.

Effect of adherence on lifetime fractures in osteoporotic women treated with daily and weekly bisphosphonates.

Patients miss doses of their osteoporosis medications, or stop taking them altogether, for a variety of reasons. Whereas the reasons have been well-studied, their consequences, at the population level, have not. The goal of this study was to estimate the number of fractures that could be prevented with optimal adherence compared with usual adherence to daily and weekly bisphosphonates in the United States (US). We developed a simulation of adherence to bisphosphonate therapy in the US. The model samples women by age and BMD from nationally representative US distributions, and tracks them over time assuming they are treated with a daily or weekly bisphosphonate. The model simulates two adherence scenarios: usual adherence and optimal adherence. The differences in fracture rates between these scenarios, as well as the medication and fracture costs, are estimated with the model. Approximately 258 (95% interval, 194-324) lifetime fractures can be prevented with optimal adherence per 1,000 bisphosphonate-treated women. For optimal adherence, these results translate to an additional lifetime medication cost of $3,800 and a lifetime savings in fracture-related costs of $2,100, for an expected net cost of $1,700 (95% interval, -$4,100 to $3,300) per woman over her lifetime. These results suggest that in patients taking daily or weekly bisphosphonate therapy, a substantial number of fractures occur that are attributable to less than optimal adherence. These results show that there is implicit value to improving adherence, both from a financial and clinical perspective.

Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis.

OBJECTIVE: To quantify the adherence of patients to drug therapy for osteoporosis in real-world settings via a systematic review and meta-analysis of observational studies. METHODS: The PubMed and Cochrane databases were searched for English-language observational studies published from January 1, 1990, to February 15, 2006, that assessed patient adherence to drug therapy for osteoporosis using the following medical subject headings and keywords: drug therapy, medication adherence, medication persistence, medication possession ratio, patient compliance, and osteoporosis. Studies were stratified into 3 groups: persistence (how long a patient continues therapy), compliance (how correctly, in terms of dose and frequency, a patient takes the medication), and adherence (a combination of persistence and compliance). A random-effects model was used to pool results from the selected studies. RESULTS: Twenty-four studies were included in the meta-analysis. The pooled database-derived persistence rate was 52% (95% confidence interval [CI], 44%-59%) for treatment lasting 1 to 6 months, 50% (95% CI, 37%-63%) for treatment lasting 7 to 12 months, 42% (95% CI, 20%-68%) for treatment lasting 13 to 24 months, returning to 52% (95% CI, 45%-58%) for treatment lasting more than 24 months. Pooled adherence rates decreased from 53% (95% CI, 52%-54%) for treatment lasting 1 to 6 months to 43% for treatment lasting 7 to 12 months (95% CI, 38%-49%) or 13 to 24 months (43%; 95% CI, 32%-54%). The pooled refill compliance estimate was 68% (95% CI, 63%-72%) for treatment lasting 7 to 12 months and 68% (95% CI, 67%-69%) for treatment lasting 13 to 24 months. The pooled self-reported compliance rate was 62% (95% CI, 48%-75%) for treatment lasting 1 to 6 months and 66% (95% CI, 45%-81%) for treatment lasting 7 to 12 months. CONCLUSION: One-third to half of patients do not take their medication as directed. Nonadherence occurs shortly after treatment initiation. Terms and definitions need to be standardized to permit comparability of technologies designed to improve patient adherence. Prospective trials are needed to assess the relationship between adherence and patient outcomes.

Health care-related economic burden of the polycystic ovary syndrome during the reproductive life span.

CONTEXT: The polycystic ovary syndrome (PCOS) is the most common endocrine abnormality of reproductive-aged women today, affecting approximately 6.6% of unselected reproductive-aged women (approximately 4 million women in the United States) (1990 National Institutes of Health criteria), and potentially represents a significant financial burden to our health care. OBJECTIVE: The objective of the study was to define, using current definitions and prevalence or incidence data, the minimal economic burden that PCOS in reproductive-aged women represents for the United States. DESIGN: The study design was a literature review. SETTING: The study was conducted at a tertiary care center. PATIENTS OR OTHER PARTICIPANTS: There were no patients or other participants. INTERVENTION(S): We performed a systematic review of the published medical literature to identify studies evaluating epidemiology of reproductive-age PCOS and its clinical consequences and costs. We tied general societal cost data for the different health consequences to reproductive-age PCOS costs, using prevalence data. MAIN OUTCOME MEASURE(S): The main measure in the study was total health care-related economic costs. RESULTS: We estimated the mean annual cost of the initial evaluation to be dollar 93 million (2.1% of total costs), that of hormonally treating menstrual dysfunction/abnormal uterine bleeding to be dollar 1.35 billion (31.0% of total), that of providing infertility care to be dollar 533 million (12.2% of total), that of PCOS-associated diabetes to be dollar 1.77 billion (40.5% of total), and that of treating hirsutism to be dollar 622 million (14.2% of total). CONCLUSIONS: The total cost of evaluating and providing care to reproductive-aged PCOS women in the United States is dollar 4.36 billion. Because the cost of the diagnostic evaluation accounted for a relatively minor part of the total costs (approximately 2%), more widespread and liberal screening for the disorder appears be a cost-effective strategy, leading to earlier diagnosis and intervention and possibly the amelioration and prevention of serious sequelae.

A systematic review of diabetes disease management programs.

OBJECTIVE: To systematically evaluate and synthesize published evidence regarding the effect of disease management programs for patients with diabetes mellitus on processes and outcomes of care. STUDY DESIGN: Systematic literature review and meta-analysis. PATIENTS AND METHODS: Computerized databases were searched for English-language controlled studies assessing the effect of diabetes disease management programs published from 1987 to 2001. Two reviewers extracted study data using a structured abstraction form. Pooled estimates of program effects on glycated hemoglobin were calculated using an empirical Bayes model. RESULTS: The pooled estimate of program effects on glycated hemoglobin was a 0.5-percentage point reduction (95% confidence interval, 0.3 to 0.6 percentage points), a modest but significant improvement. Evidence also supports program benefits in improving screening for retinopathy and foot lesions. CONCLUSIONS: Diabetes disease management programs can improve glycemic control to a modest extent and can increase screening for retinopathy and foot complications. Further efforts will be required to create more effective disease management programs for patients with diabetes mellitus.

Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction.

BACKGROUND: The role of angiotensin-receptor blockers (ARBs) in treating patients with chronic heart failure and high-risk acute myocardial infarction (MI) has been controversial, and recent clinical trials provide more information on this topic. PURPOSE: To quantify the effect of ARBs when compared with placebo (with and without background angiotensin-converting enzyme [ACE] inhibitors) and ACE inhibitors on all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and high-risk acute MI. DATA SOURCES: Data from original research published through 13 November 2003. STUDY SELECTION: Predefined criteria were used to identify 24 trials. DATA EXTRACTION: 2 reviewers independently collected information on study characteristics and data on all-cause mortality and heart failure hospitalization. DATA SYNTHESIS: 24 trials involving 38 080 patients were included. Analysis of chronic heart failure trials revealed that 1) ARBs were associated with reduced all-cause mortality (odds ratio [OR], 0.83 [95% CI, 0.69 to 1.00]) and heart failure hospitalizations (OR, 0.64 [CI, 0.53 to 0.78]) as compared with placebo; 2) for ARBs versus ACE inhibitors, all-cause mortality (OR, 1.06 [CI, 0.90 to 1.26]) and heart failure hospitalization (OR, 0.95 [CI, 0.80 to 1.13]) did not differ; 3) and for combinations of ARBs plus ACE inhibitors versus ACE inhibitors alone, all-cause mortality was not reduced (OR, 0.97 [CI, 0.87 to 1.08]) but heart failure hospitalizations were reduced (OR, 0.77 [CI, 0.69 to 0.87]). For patients with high-risk acute MI, 2 randomized trials compared ARBs with ACE inhibitors but did not reveal differences in all-cause mortality or heart failure hospitalization. LIMITATIONS: Comparative economic data between ARBs and ACE inhibitors are lacking. CONCLUSIONS: Because ACE inhibitors and ARBs do not differ in efficacy for reducing all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and in patients with high-risk acute MI, ARBs should be regarded as suitable alternatives to ACE inhibitors.

The association between quality improvement activities performed by managed care organizations and quality of care.

PURPOSE: Little data are available to assess the efforts of managed care organizations to improve quality of care. This analysis assessed differences in performance rates between organizations with and without quality improvement activities. METHODS: We reviewed 399 self-reported quality improvement activities submitted by organizations seeking accreditation by the National Committee for Quality Assurance. Processes or outcomes assessed in quality improvement activities were linked to corresponding measures in the effectiveness-of-care database of the Health Plan Employer Data and Information Set (HEDIS). Performance rates for managed care organizations with and without quality improvement activities were then compared. RESULTS: The cross-sectional analysis included 79 quality improvement activities from 50 organizations, covering 12 effectiveness-of-care categories. Each activity had a matching performance score in the database. Financial incentives for providers were associated with substantially higher performance rates in organizations employing this type of intervention. Eight effectiveness-of-care categories had at least four organizations reporting specific quality improvement activities for the care category of interest; statistically significant improvements were observed for follow-up visits for patients after hospitalization for mental illness, checkups after delivery, and screening for cervical cancer. CONCLUSION: Based on objective and audited information, the estimated effects of self-reported quality improvement activities were often small and inconsistent. In some instances, the observed effect was contrary to the expected direction. Limitations of the available dataset and the caveats of a cross-sectional study design precluded a number of analytical options. Longer-term, prospective studies are needed to explore further the relation between quality improvement activities and objective measures of clinical performance.

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review.

PURPOSE: To assess the clinical and economic effects of disease management in patients with chronic diseases. METHODS: Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group. RESULTS: Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%). CONCLUSION: Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.

Utilization of nonsteroidal anti-inflammatory drugs and antisecretory agents: a managed care claims analysis.

PURPOSE: To describe patients initiating nonsteroidal anti-inflammatory drug (NSAID) therapy with regard to gastrointestinal and cardiac risks and patterns of antisecretory agent use, and to explore the relation between therapy type and subsequent outcomes. METHODS: We studied patients aged 18 years or older who had continuous coverage from 1998 to 2001 and who had initiated treatment with cyclooxygenase-2 (COX-2) selective inhibitors or nonselective NSAIDs. Patients were categorized with respect to gastrointestinal and cardiac risk profiles. Proton pump inhibitor use within 15 days of initiating NSAID therapy was considered prophylactic. Logistic regression analysis was used to evaluate associations between treatment and hospitalization events, cardiac events, and health care costs. RESULTS: We identified 106,564 eligible NSAID initiators: 65.2% used COX-2 inhibitors and 34.8% used traditional NSAIDs. Users of COX-2 inhibitors were more likely to be at higher risk of gastrointestinal bleeding and cardiac events than were NSAID users. Proton pump inhibitor prophylaxis was most common among users of COX-2 inhibitors, but was only 11% in patients at high risk of gastrointestinal bleeding. There were no differences among treatment groups in terms of gastrointestinal or cardiac events. Initiation of COX-2 inhibitor therapy was associated with greater total health care costs. CONCLUSION: Although we found that COX-2 inhibitors were used more frequently than were traditional NSAIDs in certain groups of patients with varying cardiac or gastrointestinal risk, we did not find that their use resulted in reductions in clinical events, cotherapy with proton pump inhibitors, or costs, suggesting that a better understanding of the relation between NSAID treatment strategies and outcomes in patients with differing risk characteristics is needed.

Benefits of GM-CSF Versus Placebo or G-CSF in Reducing Chemotherapy-Induced Complications: A Systematic Review of the Literature.

Unlike granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF) is not approved for reducing the incidence or duration of chemotherapy-induced febrile neutropenia. However, some studies have been conducted in this setting. A systematic review assessing the efficacy of GM-CSF versus placebo or G-CSF in reducing chemotherapy-induced febrile neutropenia and related complications was performed. Medline was reviewed for articles published between January 1987 and March 2003 that contained specific search terms. Explicit inclusion/exclusion criteria were developed for titles, abstracts, and articles. Two researchers reviewed (kappa>/= 0.7) and divided studies according to their evaluation of GM-CSF versus placebo or versus G-CSF. Nine studies were accepted: 6 randomized controlled trials compared GM-CSF versus placebo and 3 studies compared GM-CSF versus GCSF. Three placebo-controlled trials showed that GM-CSF was ineffective in reducing the risk of chemotherapy-induced febrile neutropenia. The remaining 3 trials reported incidence of fever and not febrile neutropenia: 2 reported a significantly increased incidence of fever in the GM-CSF group, and 1 reported that more patients receiving placebo experienced fever compared with patients in the GMCSF group (P > 0.05). The 3 studies comparing GM-CSF versus G-CSF reported fever as a primary outcome also. All 3 reported higher incidence of fever in the GM-CSF group (P < 0.05). Head-to-head trials of G-CSF and GM-CSF in reducing chemotherapy-induced complications are lacking. Identified GM-CSF studies did not show significant reduction in febrile neutropenia and fever.

Effectiveness of disease management programs in depression: a systematic review.

OBJECTIVE: The authors systematically evaluated the published evidence to assess the effectiveness of disease management programs in depression. METHOD: English-language articles on depression were identified through a MEDLINE search for the period from January 1987 to June 2001. Two reviewers evaluated 16,952 published titles, identified 24 depression disease management programs that met explicit inclusion criteria, and extracted data on study characteristics, interventions used, and outcome measures. Pooled effect sizes were calculated by using a random-effects model. RESULTS: Pooled results for disease management program effects on symptoms of depression showed statistically significant improvements (effect size=0.33, N=24). Programs also had statistically significant effects on patients' satisfaction with treatment (effect size=0.51, N=6), patients' compliance with the recommended treatment regimen (effect size=0.36, N=7), and adequacy of prescribed treatment (effect size=0.44, N=11). One program with an explicit screening component showed significant improvement in the rate of detection of depression by primary care physicians (effect size=0.66); two other programs lacking a screening component showed small nonsignificant improvements in the detection rate (effect size=0.18). Disease management programs increased health care utilization (effect size=-0.10, N=8), treatment costs (effect size=-1.03, N=3), and hospitalization (effect size=-0.20, N=2). CONCLUSIONS: Disease management appears to improve the detection and care of patients with depression. Further research is needed to assess the cost-effectiveness of disease management in depression, and consideration should be given to more widespread implementation of these programs.

Effects of disease management programs on functional status of patients with rheumatoid arthritis.

OBJECTIVE: To perform a systematic review of the published literature on disease management of rheumatoid arthritis (RA) and to use meta-analysis to estimate the magnitude of benefit these programs have on functional status in patients with RA. METHODS: Computerized databases for English articles from 1966 to September 2001 were searched. Two reviewers evaluated 1,029 published titles, identified 11 studies meeting explicit inclusion criteria, and extracted data about study characteristics, interventions used, and outcomes measured. Pooled effect sizes for functional status were calculated using a random-effects model. RESULTS: Four out of 8 disease management programs showed significant improvements in functional status; however, the pooled effect size (ES) was small and statistically non-significant (ES 0.27; 95% confidence interval [95% CI] -0.01, 0.54). Studies with longer intervention durations (>5 weeks) had significantly improved patient functional status (ES 0.49; 95% CI 0.12, 0.86), compared with studies with shorter intervention durations (

Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports.

OBJECTIVE: To systematically evaluate the published evidence regarding the characteristics and effectiveness of disease management programmes. DESIGN: Meta-analysis. DATA SOURCES: Computerised databases for English language articles during 1987-2001. STUDY SELECTION: 102 articles evaluating 118 disease management programmes. MAIN OUTCOME MEASURES: Pooled effect sizes calculated with a random effects model. RESULTS: Patient education was the most commonly used intervention (92/118 programmes), followed by education of healthcare providers (47/118) and provider feedback (32/118). Most programmes (70/118) used more than one intervention. Provider education, feedback, and reminders were associated with significant improvements in provider adherence to guidelines (effect sizes (95% confidence intervals) 0.44 (0.19 to 0.68), 0.61 (0.28 to 0.93), and 0.52 (0.35 to 0.69) respectively) and with significant improvements in patient disease control (effect sizes 0.35 (0.19 to 0.51), 0.17 (0.10 to 0.25), and 0.22 (0.1 to 0.37) respectively). Patient education, reminders, and financial incentives were all associated with improvements in patient disease control (effect sizes 0.24 (0.07 to 0.40), 0.27 (0.17 to 0.36), and 0.40 (0.26 to 0.54) respectively). CONCLUSIONS: All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

The cost-effectiveness of competing strategies for the prevention of recurrent peptic ulcer hemorrhage.

OBJECTIVE: Several strategies exist for the prevention of recurrent ulcer-related hemorrhage, yet the cost-effectiveness has not been evaluated and remains uncertain. The aim of this study was to compare the cost-effectiveness of competing management strategies considering both nonsteroidal anti-inflammatory drugs status and the accuracy of Helicobacter pylori (H. pylori) testing. METHODS: Decision analysis was used to compare the cost-per-recurrent hemorrhage prevented for 11 strategies over 1 yr. Clinical and costs estimates were derived from a systematic review of the medical literature and the Medicare Fee Schedule and Drug Topics Redbook. Sensitivity analyses were performed for important variables. RESULTS: The test/retest eradication strategy with maintenance proton pump inhibitor therapy for H. pylori-negative patients was most effective (prevention of recurrence in 96.0%). The test/retest eradication strategy with maintenance histamine-2 receptor antagonist therapy for H. pylori-negative patients was least costly ($1070). The test/retest strategies were dominant with average cost-effectiveness ratios of $1118-1310/recurrent hemorrhage prevented with maintenance antisecretory therapy. The average cost-effectiveness ratios for "selective" H. pylori eradication strategies with maintenance antisecretory therapy were $1263-1673. The model was robust to varying estimates over prespecified ranges. CONCLUSIONS: Test/retest strategies for H. pylori are cost-effective for the prevention of recurrent ulcer-related hemorrhage because they maximize H. pylori detection and eradication, resulting in fewer recurrent hemorrhages and fewer patients requiring antisecretory therapy.

Physician practice patterns in the treatment of isolated systolic hypertension in a primary care setting.

The authors evaluated the treatment of isolated systolic hypertension based on medical record review of charts between 1998 and 1999 in a multispecialty physician practice group. Two age-stratified random samples of ambulatory medical records were examined (393 patients aged > or =65 years and 251 patients aged 50-64 years). The samples corresponded to the practices of 35 primary care physicians who were surveyed about their hypertension care. Isolated systolic hypertension was defined as systolic blood pressure > or =140 mm Hg and diastolic blood pressure <90 mm Hg. Results showed that isolated systolic hypertension represented 76% and 45% of uncontrolled blood pressure in the older and middle-aged samples, respectively. Isolated systolic hypertension was often undiagnosed and untreated. Physicians reported treatment thresholds and goals that were significantly less aggressive for their patients > or =65 years of age. Physician awareness and treatment of isolated systolic hypertension have not yet caught up with consensus guidelines, and older patients may be affected most by this gap.