Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model.

BACKGROUND AND OBJECTIVE: Clinicians must choose between an increasing number of medications for the treatment of pulmonary arterial hypertension (PAH) with different routes of administration, adverse effects, costs and efficacies. We constructed a decision analysis to help inform treatment choices in PAH. METHODS: We created a Markov-type model to evaluate 1-year treatment with bosentan, treprostinil, epoprostenol, inhaled iloprost, sildenafil, sitaxentan and ambrisentan. Transition probabilities were based on observed transitions between WHO functional classes, adjusted by relative risk of improvement in a 6-minute walk test. Utilities were based on reported values for each functional class, adjusted for burden of treatment administration. Costs were estimated from Medicare and Medicaid reimbursement data. Sensitivity analyses evaluated changes in efficacy, utilities and costs. RESULTS: Treatment with sildenafil was less costly and resulted in a greater gain in quality-adjusted life-years (QALYs) compared with other treatments. Treatment with ambrisentan and bosentan resulted in the same gain in QALYs as sildenafil, but at a higher cost. Sensitivity analyses had minimal impact on these results. CONCLUSIONS: Based on this model, sildenafil is a cost-effective treatment for PAH with a low price and a net increase in QALYs. The results from this analysis are a tool to help guide clinicians in deciding which PAH medications to use; however, the final decisions should be individualized because the effectiveness of therapy, resulting utilities and acceptable costs will differ with each patient.

Cost effectiveness of lopinavir/ritonavir compared with atazanavir in antiretroviral-naive patients: modelling the combined effects of HIV and heart disease.

BACKGROUND AND OBJECTIVE: The choice of initial highly active antiretroviral therapy (HAART) should take into account the need to balance efficacy, adverse event risk, resistance concerns for the treatment of HIV and treatment costs. Increased risk of coronary heart disease (CHD) may be of special concern in the selection of HAART therapy, because differences in potential CHD risk have been reported for different regimens. This study aimed to estimate the long-term combined effects of HIV disease and antiretroviral (ARV)-related risk for CHD on quality-adjusted survival and healthcare costs for ARV-naive patients. METHODS: A previously validated Markov model was updated and supplemented with the Framingham CHD risk equation. In the model, the average patient was male, aged 37 years and had a baseline 10-year CHD risk of 4.6%. Patients started with either lopinavir/ritonavir or unboosted atazanavir as the first protease inhibitor (PI). Clinical trial data were used to estimate the differences between these two therapies. The daily PI costs were $US18.52 for lopinavir/ritonavir and $US22.08 for atazanavir. Other costs were estimated from Medicaid billing databases and average wholesale drug price reports. All model costs were reported as the 2004 present value in US currency. The model's time horizon reflected a patient's lifetime, and the perspective of the analysis was that of the healthcare system and did not include indirect costs in the model cost estimates. Various CHD risk levels were tested in the sensitivity analysis. RESULTS: In the base case, the model predicted a median duration of initial PI regimen of 5.6 years for lopinavir/ritonavir and 3.8 years for atazanavir. Over 10 years, patients who started on atazanavir had 30 additional AIDS events per 100 patients. Only 0.7 additional CHD events per 100 patients occurred for those who started on lopinavir/ritonavir. The model estimated 10-year total healthcare cost savings of $US12,543 per patient in the lopinavir/ritonavir group. The lifetime incremental cost effectiveness of lopinavir/ritonavir versus atazanavir was $US6797 per quality-adjusted life-year gained. CONCLUSION: Lopinavir/ritonavir is a highly cost-effective regimen relative to atazanavir for the treatment of HIV. The effect of lopinavir/ritonavir on long-term CHD risk was minimal compared with the increased risk of AIDS/death projected for a less efficacious first PI regimen. The cost of lipid-lowering drugs and treatment of CHD for patients taking the lopinavir/ritonavir regimen was only 1.2% of the cost of AIDS care per person, which was too small to have a significant effect on the overall cost savings with lopinavir/ritonavir therapy. Thus, a decision to forgo potency and durability in an ARV regimen for an ARV-naive patient in favour of a less potent regimen with an improved lipid profile may prove to be costly over time, in terms of both budget impact and life expectancy.

Charges for hospital admissions attributable to health disparities for African-American patients, 1998-2002.

OBJECTIVE: Racial disparities exist across most major disease categories, which result in a disproportionately large number of hospital admissions for many conditions. Estimates for the financial impact of the racial admission differences for the State of South Carolina are assessed. METHODS: South Carolina hospital discharge data for 1998-2002 was used for the analysis. The database includes all-payer billing data for inpatient hospital admissions as received on the UB-92 billing file for the covered episode. Charges were inflation adjusted to 2002 constant dollars. RESULTS: For 1998-2002, there were an estimated dollar 1.6 billion in total charges for hospital admissions in South Carolina that were attributed to higher age-adjusted admission rates for African-American patients. In addition, African Americans had consistently higher hospital admission rates for disease categories that are often associated with a failure to obtain ambulatory and preventive care. CONCLUSION: This simple analysis reveals that age-adjusted hospital admission rates for African Americans in South Carolina are higher than for Caucasians, and the gap appears to be widening over time. Given the magnitude of the financial implication, interventions with even a small impact on the conditions underlying the racial disparities in hospital admissions are likely to be cost effective.

Assessment of patient knowledge of diabetic goals, self-reported medication adherence, and goal attainment.

BACKGROUND: Medication adherence is an integral aspect of disease state management for patients with chronic illnesses, including diabetes mellitus. It has been hypothesized that patients with diabetes who have poor medication adherence may have less knowledge of overall therapeutic goals and may be less likely to attain these goals. OBJECTIVE: The purpose of this study was to assess self-reported medication adherence, knowledge of therapeutic goals (hemoglobin A1C [A1C], low density lipoprotein cholesterol [LDL-C] and blood pressure [BP]), and goal attainment in adult patients with diabetes. METHODS: A survey was created to assess medication adherence, knowledge of therapeutic goals, and goal attainment for adult patients with diabetes followed at an internal medicine or a family medicine clinic. Surveys were self-administered prior to office visits. Additional data were collected from the electronic medical record. Statistical analysis was performed. RESULTS: A total of 149 patients were enrolled. Knowledge of therapeutic goals was reported by 14%, 34%, and 18% of survived patients for LDL-C, BP, and A1C, respectively. Forty-six percent, 37%, and 40% of patients achieved LDL-C, BP, and A1C goals, respectively. Low prescribing of cholesterol-lowering medications was an interesting secondary finding; 36% of patients not at LDL-C goal had not been prescribed a medication targeted to lower cholesterol. Forty-eight percent of patients were medication non-adherent; most frequently reported reasons for non-adherence were forgot (34%) and too expensive (14%). Patients at A1C goal were more adherent than patients not at goal (p=0.025). CONCLUSION: The majority did not reach goals and were unknowledgeable of goals; however, most were provided prescriptions to treat these parameters. Goal parameters should be revisited often amongst multidisciplinary team members with frequent and open communications. Additionally, it is imperative that practitioners discuss the importance of medication adherence with every patient at every visit.

ANTECEDENTES: La adherencia al tratamiento es un aspecto integral de la gestión de la enfermedad para pacientes con enfermedades crónicas, como la diabetes mellitus. Se ha sugerido que los pacientes con diabetes que tienen baja adherencia a la medicación pueden tener peor conocimiento de los objetivos terapéuticos generales y puede ser menos probable que los alcancen. OBJETIVO: El propósito de este estudio fue evaluar la adherencia auto-comunicada a la medicación, el conocimiento de los objetivos terapéuticos (hemoglobina A1C [A1C], lipoproteinas de baja densidad [LDL-C] y presión arterial), y la consecución de objetivos en adultos con diabetes. MÉTODOS: Se creó un cuestionario para evaluar la adherencia a la medicación, el conocimiento de objetivos terapéuticos, y la consecución de objetivos para adultos con diabetes seguidos en un departamento de medicina interna o de medicina de familia. Los cuestionarios se entregaron antes de la visita a la clínica. Se recogieron datos adicionales de las historias clínicas electrónicas. Se realizó un análisis estadístico. RESULTADOS: Se incluyó un total de 140 pacientes. El conocimiento de los objetivos terapéuticos fue comunicado por el 14%, 34% y 18% de los pacientes encuestados para LDL-C, PA y A1C, respectivamente. El 46%, el 37% y el 40% de los pacientes alcanzó los objetivos de LDL-C, PA, y A1C, respectivamente. La baja prescripción de hipolipemiantes fue un hallazgo secundario interesante; el 36% de los pacientes no tenían prescrito un medicamento para bajar el colesterol. El 48% de los pacientes eran incumplidores; los motivos más frecuentemente comunicados para incumplir fueron el olvido (34%) y demasiado caro (14%). Los pacientes en el objetivo de A1C eran más cumplidores que los que no estaban en el objetivo (p=0,025). CONCLUSIÓN: La mayoría no alcanza los objetivos y eran desconocedores de los objetivos; sin embargo, a la mayoría e les habían proporcionado medicamentos para tratar esos parámetros. Los parámetros objetivos deberían revisarse más a menudo entre los miembros del equipo multidisciplinario con comunicaciones abiertas y frecuentes. Además, es necesario que los facultativos discutan la importancia del cumplimiento de la medicación con capa paciente en cada visita.

Effectiveness of pharmacist-administered diabetes mellitus education and management services.

STUDY OBJECTIVES: To evaluate the effectiveness of pharmacist-administered diabetes mellitus education and management services on selected diabetes performance measures. Additional goals were to compare outcomes with goals specified for patients with diabetes by the National Committee for Quality Assurance (NCQA) and identify areas for improvement. DESIGN: One-year observational study. SETTING: Three university-based primary care clinics. PATIENTS: One hundred ninety-one patients with diabetes. Intervention. Pharmacist-provided diabetes education and management services. MEASUREMENTS AND MAIN RESULTS: Each patient was assessed for hemoglobin A1c (A1C) values, blood pressure, low-density lipoprotein cholesterol (LDL) levels, and aspirin use at baseline and at 1 year after enrollment. Cost avoidance comparators were calculated for those patients with reductions in A1C of at least 1%. Average A1C at 1 year was 7.8% (range 4.5-13.9%) versus 9.5% (range 5.4-19%) at baseline (change -1.7%, p<0.05). Seventy-two patients (38%) experienced a 1% or greater reduction in A1C. Average blood pressure decreased over the study period from 141/79 to 135/75 mm Hg (p=0.007), but average LDL levels did not change to a statistically significant extent (114 to 112 mg/dl, p>0.05). Aspirin use increased from 34% at baseline to 73% at 1 year (p<0.0001). The program achieved the A1C and LDL values required to qualify for NCQA diabetes recognition. Based on an estimated savings of $820 for each 1% decrease in A1C, cost avoidance was calculated as $59,040. CONCLUSION: Diabetes management services from clinical pharmacists achieved significant improvements in A1C values, blood pressure, and aspirin use. Continued efforts in diabetes education and management are needed to further improve clinical, economic, and humanistic outcomes.

The effect of cost construction based on either DRG or ICD-9 codes or risk group stratification on the resulting cost-effectiveness ratios.

BACKGROUND: As cost-effectiveness analyses (CEAs) are increasingly used to inform policy decisions, there is a need for more information on how different cost determination methods affect cost estimates and the degree to which the resulting cost-effectiveness ratios (CERs) may be affected. The lack of specificity of diagnosis-related groups (DRGs) could mean that they are ill-suited for costing applications in CEAs. Yet, the implications of using International Classification of Diseases-9th edition (ICD-9) codes or a form of disease-specific risk group stratification instead of DRGs has yet to be clearly documented. OBJECTIVE: To demonstrate the implications of different disease coding mechanisms on costs and the magnitude of error that could be introduced in head-to-head comparisons of resulting CERs. METHODS: We based our analyses on a previously published Markov model for HIV/AIDS therapies. We used the Healthcare Cost and Utilisation Project Nationwide Inpatient Sample (HCUP-NIS) data release 6, which contains all-payer data on hospital inpatient stays from selected states. We added costs for the mean number of hospitalisations, derived from analyses based on either DRG or ICD-9 codes or risk group stratification cost weights, to the standard outpatient and prescription drug costs to yield an estimate of total charges for each AIDS-defining illness (ADI). Finally, we estimated the Markov model three times with the appropriate ADI cost weights to obtain CERs specific to the use of either DRG or ICD-9 codes or risk group. RESULTS: Contrary to expectations, we found that the choice of coding/grouping assumptions that are disease-specific by either DRG codes, ICD-9 codes or risk group resulted in very similar CER estimates for highly active antiretroviral therapy. The large variations in the specific ADI cost weights across the three different coding approaches was especially interesting. However, because no one approach produced consistently higher estimates than the others, the Markov model's weighted cost per event and resulting CERs were remarkably close in value to one another. CONCLUSION: Although DRG codes are based on broader categories and contain less information than ICD-9 codes, in practice the choice of whether to use DRGs or ICD-9 codes may have little effect on the CEA results in heterogeneous conditions such as HIV/AIDS.