Cost-Effective Management of Stenosing Tenosynovitis.

PURPOSE: Stenosing tenosynovitis (STS) is a common condition treated by hand surgeons. Limited evidence exists to support the nonsurgical management of STS. The purpose of this study was to prospectively evaluate a cohort of patients with STS, and to determine the strategy for treating patients with this condition that is most cost effective in terms of dollars reimbursed by payers. METHODS: Prospective data were collected on patients diagnosed with STS between March 2014 and September 2014. All patients were initially treated with a corticosteroid injection. Patients with persistent symptoms were given the option of injection or surgery. A maximum of 3 injections were offered. All patients were evaluated every 6 months through office appointments or phone calls. A cost analysis was performed in our cohort using actual reimbursement rates for injections, initial and established patient visits, and facility and physician fees for surgery, using the reimbursement rates from the 6 payers covering this patient cohort. Cost savings were calculated based on offering 1, 2, and 3 injections. RESULTS: Eighty-eight digits in 82 patients were followed for an average of 21.9 months (range, 18.7-22.7 mo) after an initial corticosteroid injection. Thirty-five digits went on to surgical release, whereas 53 digits were treated nonsurgically. Had all patients initially undergone surgery, the cost would have totaled $169,088.98 ($1,921 per digit). Offering up to 3 injections yielded a potential savings of $72,730 ($826 per digit) or 43% of the total cost. For the 33 patients who underwent more than 1 injection, offering a second injection yielded potential savings of $15,956 ($484 per digit, 22.7%), and for the 7 patients presenting a third time, a third injection saved $1,986 ($283 per digit, 14.5%). CONCLUSIONS: Based on the data from our cohort, the efficient way to treat STS in terms of health care dollars spent is to offer up to 3 injections before surgical release. The first injection had the highest component of cost savings, at $826 per digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Epinephrine entrepreneur.

A Minnesota allergist continues his quest to build a better--and cheaper--drug injection device for people with severe food allergies.

[The Safety of Using Long-acting Injections : From an Opposing Position-Is It Better to Administer Long-acting Injections?].

While long-acting injections (LAI) have arrived in Japan as a second-generation antipsy- chotic drug and LAI therapy for the symptom-stabilization phase is garnering attention, deaths associated with paliperidone (PAL) -LAI were sensationally reported, attracting interest regarding the safety of LAIs. In writing this report, an opportunity to oppose LAI usage was provided, so we raise the following three issues concerning the usage of the second-generation antipsychotic LAI for the symptom-stabilization phase. 1) Particularly notable adverse reactions of LAI are those acutely developed and in some cases fatal, including malignant syndrome, diabetic ketoacidosis, torsade de pointes due to pro- longed electrocardiogram QT, and leukopenia. All antipsychotic drugs come with the risk of such adverse reactions, and since the occurrence of adverse reactions cannot be predicted prior to administration, once they have developed, the offending drugs should be immediately reduced or discontinued to remove the drug from the body ; however, since this process can- not be followed with LAIs, such fatal adverse reactions may be protracted. Moreover, in the US, adverse reactions from post injection delirium/sedation syndrome (PDSS) have been reported in relation with olanzapine (OLZ) -LAI. This is a disease state in which the drug rap- idly flows into the blood following LAI intramuscular administration along with an acute increase in blood level, leading to significant sedation (lethargy in some cases) and/or serious symptoms accompanied by delirium ; therefore, in order to minimize these risks, the US FDA has made it mandatory to use a monitoring system referred to as REMS (Risk Evaluation and Mitigation Strategy)for OLZ-LAI. Whether or not the phenomenon occurs only with OLZ-LAI remains to be seen, so careful attention must be paid. 2) In Japanese psychiatric clinical sites, the current situation is that monitoring of adverse reactions for antipsychotic drugs, particularly with outpatients, is not sufficiently carried out Under such circumstances, there remain doubts when it comes to advocating -looking to replace oral drugs with LAI in the symptom-stabilization phase. 3) Replacing oral drugs with LAI in the symptom-stabilization phase significantly increases treatment costs as well as increasing the number of hospital visits. This increase in treatment cost and number of visits may have a large impact on the adherence of the patients to the drugs.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine.

BACKGROUND: The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections. OBJECTIVE: Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues. DESIGN: Systematic review of the literature. RESULTS: USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C). CONCLUSIONS: The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Cost-Effectiveness of Injectable Extended-Release Naltrexone Compared With Methadone Maintenance and Buprenorphine Maintenance Treatment for Opioid Dependence.

BACKGROUND: The aim of this study was to estimate the cost-effectiveness of injectable extended-release naltrexone (XR-NTX) compared with methadone maintenance and buprenorphine maintenance treatment (MMT and BMT, respectively) for adult males enrolled in treatment for opioid dependence in the United States from the perspective of state-level addiction treatment payers. METHODS: A Markov model with daily time cycles was used to estimate the incremental cost per opioid-free day in a simulated cohort of adult males aged 18-65 over a 6-month period from the state health program perspective. RESULTS: XR-NTX is predicted to be more effective and more costly than methadone or buprenorphine in our target population, with an incremental cost per opioid-free day gained relative to the next-most effective treatment (MMT) of $72. The cost-effectiveness of XR-NTX relative to MMT was driven by its effectiveness in deterring opioid use while receiving treatment. CONCLUSIONS: XR-NTX is a cost-effective medication for treating opioid dependence if state addiction treatment payers are willing to pay at least $72 per opioid-free day.

Barriers to utilizing long-acting injectable antipsychotic medications.

BACKGROUND: Long-acting injectable (LAI) antipsychotic medications are superior to their oral equivalents in reducing relapse, yet schizophrenia treatment guidelines favor oral formulations. A minority of eligible patients receive LAI preparations in the United States. The purpose of the present study is to examine barriers faced by psychiatrists in implementing the use of LAI antipsychotics. METHODS: An internet survey sent to Michigan State University-affiliated psychiatrists examined psychiatrists' practice locations and characteristics, access, opinions, and barriers to utilizing LAI antipsychotic medications in patients with schizophrenia. Thirty-six psychiatrists completed the survey. RESULTS: Thirty-three psychiatrists (83%) acknowledged having patients in their practices who would benefit from LAI antipsychotics; however, only 22 (61%) had the capacity to utilize these formulations. Barriers to utilizing LAI antipsychotic medications included: 1) lack of ancillary support at the practice location; 2) personal preference for oral compounds; and 3) limited insurance coverage. Psychiatrists who had the capability of administering LAI antipsychotic compounds were 10 times more likely to utilize them when compared with others who lacked the capacity to do so (9.67% [SD=10] vs 1.43% [SD=3]; df=1; F=8.59; P<.005). CONCLUSIONS: Psychiatrists practicing in Michigan face formidable barriers to utilizing LAI agents. Strategies to mitigate these barriers are reviewed.

Sociodemographic factors influencing the use of injections in South Korean outpatient care.

PURPOSE: This study explored the relationship between sociodemographic factors and injection utilization in South Korea. METHODS: We conducted a retrospective cross-sectional analysis using 2009 prescription claims for Korean National Health Insurance beneficiaries. We analyzed the utilization, costs, and proportion of injections in the insured market for oral-injection dual-dose-form ingredients (DFIs). We included outpatients who were prescribed DFIs with no age limits. Descriptive analysis and multivariate logistic regression were performed to evaluate the predictive factors of injection use. RESULTS: Injections accounted for about 5% of outpatient utilization and costs of the study drugs. The odds of having injections were 1.3-1.6 times higher among those patients who are 70 years and older compared with those in the 20s, in smaller-sized hospitals and clinics than that in larger, and among medical institutions in rural areas than those in the capital area. The odds of having injections were increased stepwise for the age groups of 30-69 years. Injections were more likely to be prescribed for systematic hormonal preparations and drugs for the musculoskeletal system. CONCLUSIONS: The use of injections was higher among older groups, among smaller medical institutions, and among institutions in rural areas in Korean outpatient care. The difference between prescribing defined daily doses and prescribing rate for injections of the audit reports implies that Korean doctors prescribed injections often, but small doses for momentary effects in outpatient settings. Further studies are required to uncover the underlying causes of the high prevalence of injection use in older or rural populations and smaller institutions.

Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction.

BACKGROUND: Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain. AIMS: To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction. METHOD: Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources. RESULTS: Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15 805 v. £13 410 injectable methadone and £10 945 injectable heroin; P = n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin. CONCLUSIONS: Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.

Effects of the commercial in ovo injection of 25-hydroxycholecalciferol on the hatchability and hatching chick quality of broilers.

The effects of the in ovo injection of commercial diluent containing various levels of 25-hydroxycholecalciferol [25(OH)D3] on hatchability and hatching chick quality variables in Ross × Ross 708 broilers were examined in 2 trials. All treatment groups, each containing 21 and 40 eggs in trials 1 and 2, respectively, were randomly represented on each of 10 replicate tray levels of a single-stage incubator. On 18 d of incubation (doi), eggs were subjected to 1 of 6 treatments using a commercial multi-egg injector. Treatments included noninjected and diluent-injected controls, along with those that received diluent containing 0.15, 0.30, 0.60, or 1.20 µg of 25(OH)D3 in trial 1 and 0.20, 0.60, 1.80, or 5.4 µg of 25(OH)D3 in trial 2. Hatchability of injected eggs (HI) was recorded on 20.5, 21.0, and 21.5 doi, and embryonic mortalities through 21.5 doi were determined. On 21.0 doi in each trial, the BW, body length, and weights and moisture concentrations of the livers and yolk sacs of male and female chicks in each replicate group were determined. In a preliminary trial, the in ovo injection of 0.60 µg of 25(OH)D3 on 18 doi significantly elevated its serum level concentrations in embryos on 19.25 doi. In both trials, the HI of noninjected controls through 21.0 doi was higher than that of diluent-injected controls. In trial 1, the HI of eggs on 21.0 doi after being injected with 0.30, 0.60, or 1.20 µg of 25(OH)D3 was higher compared with that of diluent-injected controls, and in trial 2, the HI of eggs on 21.0 and 21.5 doi after being injected with 0.60 µg of 25(OH)D3 was higher compared with that of diluent-injected controls. In conclusion, the in ovo injection of 0.60 µg of 25(OH)D3 may be used to alleviate depressions in HI in Ross × Ross 708 broiler hatching eggs that can occur in response to the in ovo injection of commercial diluent.

Serve the people or close the sale? Profit-driven overuse of injections and infusions in China's market-based healthcare system.

Treatment by injection or infusion is widespread in China. Using the common cold as a tracer condition, we explored the reasons for over-prescription of injections and infusions in Guizhou, China. Interviews with prescribers, patients and key informants were supplemented by focus groups. These revealed how historical ideas encourage unnecessary use of percutaneous treatment: faith in the healing power of needles is locally attributed to association with acupuncture. Many patients and some staff believe that injections per se are therapeutic. However, the structure of health service financing and remuneration now reinforces this irrational faith. Market-based reforms have attempted to control costs and increase productivity with an incentive scheme which rewards prescribers financially for over-prescription in general and for use of injections and infusions in particular. Aggressive marketing has displaced oral treatment from health facilities into independent pharmacies, leaving doctors functioning mainly as injection providers. There is a need for a multi-faceted response encompassing education and reform of financial incentives to reduce the use of unnecessary treatment.

A discrete choice experiment to understand preferences of patients with type 2 diabetes treated with injectable non-insulinic agents.

OBJECTIVE: To identify and evaluate the Spanish diabetes mellitus type 2 patients' preferences on injection and medication frequency and complexity of the treatment of diabetes. Additionally, patients' willingness to pay is evaluated. METHODS: A total of 180 patients recruited from five health care centres in Spain completed a discrete choice experiment survey designed to evaluate patients' preferences over three attributes discriminating by age, sex and patients experience with previous treatment. The resulting model was analysed using a conditional (fixed-effects) logistic regression. RESULTS: Naïve and non-naïve patients were willing to pay 83.25€ for a 'no preparation required' dose. In addition, both groups of patients were willing to pay 44.30€ for a 'simple preparation' dose. In terms of treatment frequency, no-naïve patients preferred a daily injection with freedom of timing before a daily scheduled injection, willing to pay 22.20€. In addition, no-naïve patients were willing to pay 34.61€ for a weekly injection. Finally, the most valued treatment change in naïve patients was to exchange a daily scheduled injection for a weekly injection, willing to pay 14.35€ for that change. CONCLUSIONS: This study shows that patients highly value the avoidance of injections, with weekly dosing clearly preferred over daily dosing. Of the other attributes, a 'no preparation required' dose is clearly preferred over a 'simple preparation' dose. These findings may provide a better understanding of what patients prefer and value in their treatment and provide guidance for clinicians making therapeutic decisions regarding T2DM treatments.

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

OBJECTIVE: To analyse safety risks in injectable medications. To assess the potential impact and pharmacoeconomic aspects of safety tools. DESIGN: The injectable drug process was prospectively assessed using a failure modes, effects and criticality analysis. Criticality indexes were estimated based on their likelihood of occurrence, detection probability and potential severity. The impact of 10 safety tools on the criticality index was calculated and extrapolated to all drugs injected daily. Yearly costs for a reduction in criticality by 1 point (=1 quali) per day were estimated. SETTING: Paediatric and neonatal intensive care units in a University Hospital. PARTICIPANTS: Two paediatric nurses, a neonatologist, three hospital pharmacists. INTERVENTIONS: Qualitative and quantitative risk assessment. MAIN OUTCOME MEASURES: Failure modes, criticality indexes, cost-efficacy ratios. RESULTS: Thirty-one failure modes identified, with the mean of their entire criticality indexes totalling 4540. The most critical failure mode was microbial contamination. The following gains were predicted: 1292 quali (46 500 per day by extrapolation) from ready-to-use syringes, 1201 (72 060) by employing a clinical pharmacist, 996 (59 780) from double check by nurses and 984 (59 040) with computerized physician order entry. The best cost-efficacy ratios were obtained for a clinical pharmacist (1 quali = 0.54 euros), double check (1 quali = 0.71 euros) and ready-to-use syringes (1 quali = 0.72 euros). Computerized physician order entry showed the worst cost-efficacy ratio due to a very high investment costs (1 quali = 22.47 euros). CONCLUSION: Based on our risk and pharmacoeconomic analyses, clinical pharmacy and ready-to-use syringes appear as the most promising safety tools.

The effectiveness of harm reduction in preventing HIV among injecting drug users.

There is now compelling evidence that harm reduction approaches to HIV prevention among injecting drug users are effective, safe and cost-effective. The evidence of effectiveness is strongest for needle and syringe programs and opioid substitution treatment. There is no convincing evidence that needle and syringe programs increase injecting drug use. The low prevalence approximately 1%) of HIV among injecting drug users reflects the early adoption and rapid expansion of harm reduction in Australia. Countries that have provided extensive needle and syringe programs and opioid substitution treatment appear to have averted an epidemic, stabilised or substantially reduced the prevalence of HIV among injecting drug users. However, despite decades of vigorous advocacy and scientific evidence, the global coverage of needle and syringe programs and opioid substitution treatment falls well short of the levels required to achieve international HIV control.

Overview of insulin delivery pen devices.

OBJECTIVES: To review currently available insulin delivery pen devices for use in diabetes and to describe their primary benefits and drawbacks in comparison with the traditional vial/syringe method of insulin administration. DATA SOURCE: Not applicable. SUMMARY: Insulin delivery pen devices are available for most types of insulin, including all insulin analog preparations and insulin premixes with rapid-acting insulin or regular insulin with neutral protamine Hagedorn insulin. Some devices have a replaceable insulin cartridge (categorized as reusable or durable); other devices are prefilled and are disposed of after the insulin reservoir is emptied. Insulin delivery pens offer several advantages over the vial and syringe method of injection, including greater ease and discretion of use and improved portability, adherence, and dosing accuracy. The tactile and auditory feedback provided by the dosing dial on insulin delivery pen devices may be particularly helpful for patients who have impaired manual dexterity or vision. Studies also show a strong preference among patients in favor of insulin delivery pen devices compared with the vial/syringe method. Finally, despite greater per-unit cost, insulin delivery pen devices have also been associated with reductions in health resource use and associated costs compared with vial/syringe therapy. CONCLUSION: Insulin delivery pen devices offer another option to patients with diabetes for insulin administration. They are associated with not only improved ease of use but also improved dosing accuracy and adherence to therapy. To develop the most suitable insulin regimens for their patients, health providers should be informed about available insulin delivery pen devices.