Assessment of the prognostic significance of low gradient severe aortic stenosis and preserved left ventricular function requires the integration of the consistency of stroke volume calculation and clinical data.

BACKGROUND: This study was to evaluate the prognostic significance of low gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF) with the integration of echocardiographic and clinical data. METHODS: The study included 172 patients with LG SAS (AVAi ≤ 0.6 cm2 /m2 , mean aortic pressure gradient < 40 mm Hg) and LVEF (≥ 50%). LV outflow tract diameters were measured at both the aortic valve annulus and 5 mm below the annulus for the measurement consistency. Patients were divided into the low flow LG SAS (LF/LG SAS: SVi < 35mL/m2 and AVAi ≤ 0.6 cm2 /m2 ) and normal-flow LG SAS groups (NF/LG SAS: SVi ≥ 35mL/m2 and AVAi ≤ 0.6 cm2 /m2 ). Echocardiographic findings and clinical data were systematically analyzed with mean follow-up of 3.0 ± 1.6 years. RESULTS: LF/LG SAS had significantly smaller AVAi, lower SVi, a higher prevalence of atrial fibrillation (28% vs 12% P = .01) and diabetes (47% vs 27% P = .007) and lower 3-year cumulative survival than NF/LG SAS. Multivariable analysis showed that dyspnea, renal dysfunction (CI 1.42-3.99, P < .01), left atrial diameter, and SVi were independently associated with an increased risk for all-cause mortality. Aortic valve intervention (AVI) improved survival in LF/LG SAS (68% vs 48%, P < .05) in comparison with medical management (HR: 4.20, CI: 1.12-15.76, P = .03), but only modestly in NF/LG SAS (75% vs 65% P > .05). CONCLUSION: Outcome of LG SAS was independently associated with clinical characteristics. AVI likely improved outcome of LF/LG SAS who had high-risk clinical characteristics and unfavorable echocardiographic findings.

Long-term opioid users with chronic noncancer pain: Assessment of opioid abuse risk and relationship with healthcare resource use.

OBJECTIVE: Identify opioid abuse risk factors among chronic noncancer pain (CNCP) patients receiving long-term opioid therapy and assess healthcare resource use (HRU) among patients at elevated abuse risk. DESIGN: Data were obtained from an integrated administrative claims database. Classification and Regression Tree (CART) analysis identified risk factors potentially predictive of opioid abuse, which were used to classify the overall population into cohorts defined by levels of abuse risk. Multivariable logistic regression compared HRU across risk cohorts. SETTING: Retrospective cohort study. PATIENTS, PARTICIPANTS: 21,072 patients aged ≥18 years diagnosed with ≥1 of 5 types of CNCP and a prescription for Schedule II or III/IV opioid medication used long-term (≥90 days). MAIN OUTCOME MEASURES: (1) Opioid abuse risk factors; (2) HRU differences between risk cohorts. RESULTS: CART analysis identified four groups at elevated opioid abuse risk defined by three factors (age, daily opioid dose, and total days' supply of opioids); sensitivity: 70.3 percent, specificity: 74.1 percent, and positive predictive value: 5.6 percent. The analysis results were used to classify patients into low-risk (72.5 percent), at-risk (25.4 percent), and opioid-abuser (2.2 percent) cohorts. In multivariable analysis, emergency department (ED) use was higher among at-risk vs low-risk patients (odds ratio [OR]: 1.14; p<0.05); hospitalization and ED visits were higher for opioid-abusers vs low-risk patients (OR: 2.33 and 2.14, respectively; p<0.05). CONCLUSIONS: This study identifies a subpopulation of CNCP patients at risk of opioid abuse. However, limited sensitivity and specificity of criteria defining this subpopulation reinforce the importance of physician discretion in patient-level treatment decisions.

Humanistic and economic burden of nausea and vomiting among migraine sufferers.

BACKGROUND: While studies have demonstrated the economic burden of migraines in terms of quality of life, health care resource use (HRU), and costs, there exists a notable paucity of data comparing such outcomes among migraineurs with nausea and vomiting (N/V) and those without. The current study aimed to address this gap. METHODS: This was a retrospective study using data from the 2013 US National Health and Wellness Survey, a cross-sectional, internet-based survey. Respondents self-reported their migraine with or without N/V along with demographics and outcomes including depression (Patient Health Questionnaire total score; PHQ-9), sleep problems (11-item total score of sleep problems), HRU (number of physician visits, emergency room [ER] visits, and hospitalizations) and Work Productivity and Activity Impairment-General Health Scale (WPAI-GH), and associated mean annual costs. Generalized linear models, adjusting for covariates, assessed the burden of N/V on all outcomes. RESULTS: Among all migraineurs (N=7,855), 73.4% were female, mean age was 41.82 years old, and 57.6% reported experiencing N/V. Adjusting for covariates, migraineurs with N/V vs without N/V had higher mean PHQ-9 scores (7.91 vs 7.02, p<0.001) and mean sleep problems (3.29 vs 2.64, p<0.001). Mean ER visits were more frequent among migraineurs with N/V than those without N/V (0.48 vs 0.38, p=0.001). This difference translated into a 26.3% increase in estimated mean ER costs (N/V=US$1,499 vs without N/V=US$1,187, p=0.002). Mean percentage activity impairment was higher in migraineurs with N/V than in those without N/V (37.73% vs 35.12%, p=0.002) and migraineurs with N/V had higher work productivity loss costs (N/V=US$10,344 vs without N/V=US$9,218, p=0.016). CONCLUSION: Migraine patients with N/V reported worse depression, sleep problems, and activity impairment, and higher ER visits than those without N/V. Migraine with N/V was also associated with an increase in mean annual ER visit costs and work productivity loss costs. Study findings suggest unmet needs with current treatment options for migraine patients with N/V.

Clinical and economic studies of eptifibatide in coronary stenting.

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.

Cost effectiveness of radial access for diagnostic cardiac catheterization and coronary intervention.

OBJECTIVES: To evaluate the cost effectiveness of diagnostic cardiac catheterizations (CATH) and coronary interventions (PCI) performed using radial artery (RA) access compared to femoral artery (FA) access. BACKGROUND: CATH and PCI performed from the RA reduce access site complications compared to FA, but can increase procedure duration, and equipment and contrast use. Whether resulting increases in utilization costs are offset by reduced costs of complications is uncertain. METHODS: In all, 6,726 CATH and PCI (RA, 3,368; FA, 3,358) were performed from January 2009 to December 2011. Procedural costs and cost of access site complications were compared for propensity-matched CATH (RA and FA, 1,222) and PCI (RA and FA, 570) throughout a complete transition of the lab from a preferred FA to preferred RA strategy. RESULTS: Adjusted mean total costs were $10 more (95% confidence interval $613 less to $610 more) for RA-CATH versus FA-CATH and $732 less ($1,345 less to $156 less) for RA-PCI versus FA-PCI. The incremental cost per vascular or bleeding complication avoided with RA-CATH was $1,265, whereas RA was economically dominant with lower costs and fewer complications compared to FA for PCI and all procedures. CONCLUSIONS: Radial access for CATH and PCI reduced access site complications and overall costs compared to FA procedures with similar baseline clinical and procedural characteristics, making it an economically advantageous strategy.

Cost-effectiveness of rosuvastatin in comparison with generic atorvastatin and simvastatin in a Swedish population at high risk of cardiovascular events.

BACKGROUND: To assess the long-term cost-effectiveness of rosuvastatin therapy compared with generic simvastatin and generic atorvastatin in reducing the incidence of cardiovascular events and mortality in a Swedish population with Framingham risk ≥20%. METHODS: A PROBABILISTIC MONTE CARLO SIMULATION MODEL BASED ON DATA FROM JUPITER (THE JUSTIFICATION FOR THE USE OF STATINS IN PREVENTION: an Intervention Trial Evaluating Rosuvastatin) was used to estimate the long-term cost-effectiveness of rosuvastatin 20 mg daily versus simvastatin or atorvastatin 40 mg for the prevention of cardiovascular death and morbidity. The three- stage model included cardiovascular event prevention simulating the 4 years of JUPITER, initial prevention beyond the trial, and subsequent cardiovascular event prevention. A Swedish health care payer perspective (direct costs only) was modeled for a lifetime horizon, with 2008/2009 as the costing period. Univariate and probabilistic sensitivity analyses were performed. RESULTS: The incremental cost per quality-adjusted life-year (QALY) gained with rosuvastatin 20 mg over simvastatin or atorvastatin 40 mg ranged from SEK88,113 (rosuvastatin 20 mg versus simvastatin 40 mg; Framingham risk ≥30%; net avoidance of 34 events/1000 patients) to SEK497,542 (versus atorvastatin 40 mg: Framingham risk ≥20%; net avoidance of 11 events/1000 patients) over a lifetime horizon. Probabilistic sensitivity analyses indicated that at a willingness-to-pay threshold of SEK500,000/QALY, rosuvastatin 20 mg would be cost-effective for approximately 75%-85% of simulations relative to atorvastatin or simvastatin 40 mg. Sensitivity analyses indicated the findings to be robust. CONCLUSION: Rosuvastatin 20 mg is cost-effective over a lifetime horizon compared with generic simvastatin or atorvastatin 40 mg in patients at high cardiovascular risk in Sweden.

Cost-effectiveness of rosuvastatin 20 mg for the prevention of cardiovascular morbidity and mortality: a Swedish economic evaluation of the JUPITER trial.

OBJECTIVE: This study estimated the long-term health outcomes, healthcare costs, and cost-effectiveness of rosuvastatin 20 mg therapy in primary prevention of major cardiovascular disease (CVD) in a Swedish population. METHODS: Based on data from the JUPITER trial, long-term CVD outcomes with rosuvastatin vs no active treatment were estimated for patients with an elevated baseline CVD risk (Framingham CVD score >20%, sub-population of JUPITER population) and for a population similar to the total JUPITER population. Using a decision-analytic model, trial CVD event rates were combined with epidemiological and cost data specific for Sweden. First and subsequent CVD events and death were estimated over a lifetime perspective. The observed relative risk reduction was extrapolated beyond the trial duration. Incremental effectiveness was measured as life-years gained (LYG) and quality-adjusted life-years (QALYs) gained. RESULTS: Treating 100,000 patients with rosuvastatin 20 mg was estimated to avoid 14,692 CVD events over the lifetime (8021 non-fatal MIs, 3228 non-fatal strokes, and 4924 CVD deaths) compared to placebo. This translated into an estimated gain of 42,122 QALYs and 36,865 total life years (LYG). Rosuvastatin was both more effective and less costly over a lifetime perspective, and rosuvastatin is subsequently a dominant alternative compared to no treatment in the assessed population. Using the overall JUPITER population, rosuvastatin was dominant for the lifetime horizon. In the sensitivity analysis, rosuvastatin was the dominant treatment strategy over a 20-year time horizon, and cost-effective with an incremental cost-effectiveness ratio (cost per QALY) of SEK 1783 over a 10-year time horizon. LIMITATIONS: Some model inputs were derived from literature or other data sources, but uncertainty was controlled by sensitivity analyses. CONCLUSIONS: Results indicate that rosuvastatin 20 mg treatment is a cost-effective option vs no-treatment in patients with Framingham CVD risk >20% in Sweden and might even be cost saving if taking a long-term perspective.

Cost-effectiveness of drug-eluting stents versus bare metal stents in clinical practice.

BACKGROUND: Drug-eluting stents (DES) reduce the need for repeat target revascularization (TVR) compared with bare metal stents (BMS) but are more costly. The objective was to evaluate the cost-effectiveness of DES versus BMS. METHODS AND RESULTS: We evaluated clinical outcomes and costs of care over 3 years in 1147 undergoing BMS before the availability of DES and 1247 DES patients at Wake Forest University Baptist Medical Center from 2002 to 2005. Costs for index stenting, TVR, and clopidogrel use were assessed. The 2 groups were well matched for baseline characteristics. Index stenting costs were $1846 higher per patient for DES versus BMS ($1737 more to $1950 more). At 3 years, absolute TVR rates were 15.2 per 100 DES patients and 24.1 per 100 BMS patients, and as a result, cumulative TVR-related costs were $2065 less per patient for DES versus BMS ($3001 less to $1134 less). Including the cost of clopidogrel, the incremental cost-effectiveness ratio per TVR avoided with DES was $4731 through 1 year, $4703 through 2 years, and $6379 through 3 years. CONCLUSIONS: At 3 years, the higher index cost of DES versus BMS was completely offset by lower TVR-related costs. However, because of extended clopidogrel use for DES, the incremental cost-effectiveness ratio per TVR avoided ranged from $4703 to $6379 over 3 years. These unadjusted observational findings provide support for the continued use of DES in routine practice but highlight the important impact of prolonged dual antiplatelet use on the cost-effectiveness of this technology.

Medical and cost burden of atherosclerosis among patients treated in routine clinical practice.

OBJECTIVE: This investigation estimated medical costs attributable to treatment of patients diagnosed with atherosclerosis in routine US clinical practice. METHODS: Using Medstat MarketScan claims data, direct costs of care and rates of cardiovascular (CV) events (i.e., myocardial infarction, stroke, revascularization) were examined for patients≥18 years of age with and without a diagnostic code for atherosclerosis from 1/1/2002 through 12/31/2004. Patients with an atherosclerosis ICD-9 code who had no history of CV events in the preceding 12 months (n=75,469) were evaluated. A comparison cohort (n=238,702) was matched on age, gender, geographic region, enrollment time period, and Charlson comorbidity index to estimate incremental costs attributable to atherosclerosis. Differences between patient groups were tested for CV event rates per 1,000 patients and monthly costs for 6 and 12 months before and after diagnosis. RESULTS: Patients had a mean age of 58 years, 52% men, and a comorbidity index of 0.49. Patients diagnosed with atherosclerosis had significantly higher (p<0.001) rates of CV events (240/1000) after diagnosis, compared with patients without atherosclerosis (32/1000). Mean direct cost of care for patients diagnosed with atherosclerosis was $579/month for 12 months before and $1,074/month for 12 months after diagnosis, an 85% increase. Change in mean annual costs pre/post-index date was $5,232 ($436/month) higher among patients with than those without atherosclerosis (p<0.001). LIMITATIONS: The study population was restricted to patients with diagnosed clinical atherosclerosis based on specific ICD-9 codes. Matching of the patient cohorts was based on observed characteristics and other unobserved differences may exist. CONCLUSIONS: Patients with diagnosed atherosclerosis incur significant clinical and economic burden, indicating a need for earlier diagnosis and treatment of atherosclerosis to help in reducing this burden.

Cost effectiveness of rosuvastatin in patients at risk of cardiovascular disease based on findings from the JUPITER trial.

OBJECTIVE: This study assessed the long-term cost effectiveness of rosuvastatin therapy compared with placebo in reducing the incidence of major cardiovascular (CVD) events and mortality. METHODS: A probabilistic Monte Carlo simulation model estimated long-term cost effectiveness of rosuvastatin therapy (20 mg daily) for the prevention of CVD mortality and morbidity. The model included three stages: (1) CVD prevention simulating the 4 years of the JUPITER trial, (2) initial CVD prevention beyond the trial, and (3) subsequent CVD event prevention. A US payer perspective was assessed reflecting direct medical costs, and up to a lifetime horizon. Sensitivity analyses tested the robustness of the model estimates. RESULTS: For a hypothetical cohort of 100,000 patients at moderate and high risk of CVD events based on Framingham risk of ≥10%, estimated quality-adjusted life-years (QALYs) gained with rosuvastatin therapy compared with placebo was 33,480 over a lifetime horizon, and 25,380 and 9916 over 20-year and 10-year horizons, respectively. Approximately 12,073 events were avoided over the lifetime; 6,146 non-fatal MIs, 2905 non-fatal strokes, and 4030 CVD deaths avoided. Estimated incremental cost-effectiveness ratio (ICER) for cost per QALY was $7062 (lifetime), $10,743 (20-year horizon), and $44,466 (10-year horizon). For a hypothetical cohort similar to the overall JUPITER population, the cost per QALY ICER was $11,025 for the lifetime and $60,112 for a 10-year horizon. LIMITATIONS: The cost-effectiveness comparison of rosuvastatin 20 mg was against no active treatment (as opposed to an alternative statin) due to lack of comparative cardiovascular morbidity and mortality risk reduction data for other statins in a population similar to the JUPITER trial population. The analysis was conducted from the payer perspective and lack of inclusion of indirect costs limit interpretability of results from a societal perspective. CONCLUSIONS: Treatment with rosuvastatin 20 mg daily, is a cost-effective treatment alternative to no treatment in patients at a higher risk (Framingham risk≥10%) of CVD.

Health systems and immunization financing for human papillomavirus vaccine introduction in low-resource settings.

This descriptive qualitative study synthesizes health system and immunization financing assessments performed through formative research in India, Peru, Uganda, and Vietnam using a non-probability sample of national and sub-national stakeholders; and recommends appropriate and effective strategies for HPV vaccine delivery in low-resource settings. We conclude that maximum feasibility and acceptability and lowest cost for delivering HPV vaccine can be achieved by implementing through national immunization programs; by partnering with other sectors, such as education and maternal-child health; by strengthening existing human resources and cold chain infrastructures where needed; and finally, by considering schools for reaching the target population.

Medicare-eligible patients diagnosed with atherosclerosis: patterns in statin therapy and lipid monitoring.

BACKGROUND: This study assessed lipid-monitoring and statin therapy patterns in routine clinical practice for Medicare-eligible patients diagnosed with atherosclerosis. METHODS: A retrospective study using a random sample of 1 million patients (>17 years of age) from a US outpatient electronic medical record database was conducted with patients > or =65 years of age having a diagnostic code for atherosclerosis between January 2004 and March 2006. Use of statin therapy at the time of and for 12 months after atherosclerosis diagnosis, in addition to patient demographics, comorbid conditions, baseline and post-diagnosis LDL-C, were recorded. RESULTS: In the million-patient sample, 3303 patients were > or =65 years of age and had a diagnostic code of atherosclerosis. Overall, 63% of these patients were not prescribed statin therapy at the time of or within 12 months after diagnosis. Lipid monitoring within 6 months before diagnosis occurred in 37% of patients. Of those with a recorded baseline LDL-C (n = 1213), 50% had LDL-C > or =100 mg/dL and 87% had LDL-C > or =70 mg/dL. Among patients with baseline LDL-C > or =100 mg/dL, 55% were not prescribed statin therapy at or after their diagnosis compared with 49% of patients with baseline LDL-C <100 mg/dL (p = 0.0001). There were significantly more patients who were prescribed statin therapy with LDL-C <100 mg/dL after diagnosis (67%) than at diagnosis (55%) (p = 0.0008). LIMITATIONS: Patients were required to have an ICD-9 diagnosis of atherosclerosis, which may have underestimated those with atherosclerosis that was not coded specifically as atherosclerosis. Because the study included patients treated in physician practice with an electronic medical record system (EMR), they may be different from patients who are treated by physicians not equipped with an EMR. Pharmacy data were the prescription ordered and not the drug claim indicating that the prescription was dispensed. This may overestimate the statin therapy utilization estimates. CONCLUSIONS: A substantial gap in the management of diagnosed atherosclerosis was found among Medicare-eligible patients treated in the usual-care setting. There is a need to raise awareness of the importance of lipid monitoring and treatment of hypercholesterolemia in this at-risk population.

Medical management of patients before the incidence of a cardiovascular event.

OBJECTIVE: We sought to examine the diagnoses and medical management patterns of patients before the incidence of a cardiovascular (CV) event. METHODS: A retrospective study of claims data from a national managed care plan was conducted. Eligible patients had a myocardial infarction, stroke, or revascularization between January 1, 2004 and December 31, 2005, and at least 3 years of continuous enrollment before the CV event. Patients were stratified by whether or not they had a diagnosis of atherosclerosis in the 3 years before the CV event. Diagnostic testing, lipid monitoring, and statin treatment patterns were assessed during the 3-year period before the CV event. RESULTS: There were 16,543 patients with a CV event, and 65% had no previous diagnosis of atherosclerosis. For all patients, 58% were men, and mean age was 60 years. Angiography or cardiac imaging was performed in <3% of patients, and cardiac stress testing was performed in 13% of patients before the event. Only 19% of patients had ≥1 lipid test in the 12 months and 32% in the 3 years before the event, and their 12-month mean low-density lipoprotein cholesterol was 113 mg/dL. Thirty-four percent of patients were on statin therapy within the 3 years before event. The patient subgroup diagnosed with atherosclerosis had significantly more patients with cardiac testing, lipid monitoring, and statin therapy compared with patients with no previous diagnosis of atherosclerosis. CONCLUSION: These results from an actual clinical practice dataset indicate opportunities for improved detection and management of underlying atherosclerotic heart disease to avoid future cardiovascular events.

Cost-effectiveness analysis of rosuvastatin versus atorvastatin, simvastatin, and pravastatin from a Canadian health system perspective.

OBJECTIVE: The primary objective of this study was to assess the cost-effectiveness of the most commonly prescribed doses of rosuvastatin, atorvastatin, simvastatin, and pravastatin for managing various lipid parameters in patients with hypercholesterolemia over a 1-year time horizon from a Canadian health care perspective. METHODS: Incremental cost-effectiveness ratios (ICERs) were estimated for branded rosuvastatin compared with branded atorvastatin, generic simvastatin, and generic pravastatin in patients with hypercholesterolemia in terms of percent reduction in low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC)/high-density lipoprotein cholesterol (HDL-C) ratio, as well as in TC, HDL-C, triglycerides (TG), apolipoprotein (Apo) B, the ApoB/ApoA-I ratio, and attainment of the Canadian LDL-C goal. The pharmacoeconomic model was constructed for a 1-year time horizon using efficacy data from a randomized, open-label trial including 2268 adults and the wholesale acquisition costs of branded rosuvastatin and atorvastatin and generic simvastatin and pravastatin in British Columbia. RESULTS: The most commonly prescribed doses of each of the 4 statins in British Columbia were as follows: rosuvastatin 10 mg (75.8% of all rosuvastatin doses); atorvastatin 10 and 20 mg (46.4% and 35.3%, respectively, of all atorvastatin doses); simvastatin 20 and 40 mg (42.5% and 31.8%, respectively, of all simvastatin doses); and pravastatin 20 and 40 mg (55.0% and 34.1%, respectively, of all pravastatin doses). Rosuvastatin 10 mg was dominant (ie, was more effective at a lower cost) relative to atorvastatin 10 and 20 mg, simvastatin 20 and 40 mg, and pravastatin 40 mg in terms of reductions in LDL-C, TC/ HDL-C ratio, TC, ApoB, and ApoB/ApoA-I ratio, increases in HDL-C, and attainment of the LDL-C goal. Compared with pravastatin 20 mg, the ICER per percent reduction in LDL-C, TC/HDL-C ratio, TC, TG, ApoB, or ApoB/ApoA-I or increase in HDL-C ranged from $3.89 to $26.07; the value for 1 additional patient achieving the LDL-C goal was $419.75. When the statin doses were aggregated based on the Canadian statin-utilization pattern, rosuvastatin was dominant relative to atorvastatin on all effectiveness measures evaluated. When rosuvastatin was compared with generic simvastatin and pravastatin, the annual costs for 1 additional patient achieving the LDL-C goal were $144.51 and $373.91, respectively. Based on the sensitivity analysis, rosuvastatin was associated with the highest probability of cost-effectiveness compared with the other statins over a broad range of monetary values per unit of clinical effect. CONCLUSION: When percent changes in lipid parameters and rates of LDL-C goal attainment were considered in patients with hypercholesterolemia in British Columbia, rosuvastatin 10 mg was more cost-effective than the most frequently used doses of atorvastatin (10 and 20 mg), generic simvastatin (20 and 40 mg), and generic pravastatin (20 and 40 mg).

Statin cost-effectiveness comparisons using real-world effectiveness data: formulary implications.

OBJECTIVE: To compare the effectiveness and cost-effectiveness among generic and branded statins in routine clinical practice. METHODS: Retrospective database study of patients, 18+, who were newly prescribed statin therapy. Statin effectiveness and cost-effectiveness in reducing low-density lipoprotein cholesterol (LDL-C) and attaining LDL-C goals were evaluated. RESULTS: Of 10,421 eligible patients, % LDL-C reduction was significantly greater (P < 0.001) with rosuvastatin (-31.6%) than other statins (-13.9 to -21.9%). Percentage of patients at moderate/high risk attaining LDL-C goal was higher (P < 0.001) for rosuvastatin (76.1%) versus other statins (57.6-72.6%). Rosuvastatin was more effective and less costly than atorvastatin. Among generic statins, simvastatin required >61% discount to branded price to achieve similar cost-effectiveness as generic lovastatin. CONCLUSIONS: In clinical practice, rosuvastatin is more effective and less costly in lowering LDL-C and LDL-C goal attainment compared with atorvastatin. Simvastatin was more cost-effective compared with lovastatin if >61% discount to branded price was achieved.

Lipid levels and low-density lipoprotein cholesterol goal attainment in diabetic patients: rosuvastatin compared with other statins in usual care.

OBJECTIVE: To compare change in low-density lipoprotein cholesterol (LDL-C) levels and National Cholesterol Education Program (NCEP) Adult Treatment Panel III LDL-C goal attainment in diabetic patients treated with rosuvastatin versus other statins in a large, managed care health plan. RESEARCH DESIGN AND METHODS: This retrospective cohort analysis used medical and pharmacy claims linked to laboratory results from a commercial/MedicareAdvantage health plan. Study participants were >or= 18 years of age, had a diagnosis of diabetes, were newly treated with statins from 8/1/03 to 2/28/05, and were considered at high risk for cardiovascular events as defined by NCEP guidelines. Subjects were continuously enrolled for 12 months pre-index and >or= 30 days post-index, with variable follow-up until therapy discontinuation or end of health plan eligibility. MAIN OUTCOME MEASURES: Change in LDL-C from baseline, and attainment of NCEP LDL-C goal among patients not at goal before starting therapy. RESULTS: A total of 3337 adult patients with diabetes were identified with new use of statin therapy during the identification period. A total of 9% (n = 301) started on rosuvastatin, 49.4% (n = 1,649) on atorvastatin, 20.7% (n = 690) on simvastatin, 7.0% (n = 234) on pravastatin, 11.7% (n = 391) on lovastatin and 2.2% (n = 72) on fluvastatin. After controlling for covariates, rosuvastatin patients experienced a significantly greater decrease in LDL-C from baseline (38.7%) than patients taking atorvastatin (34.2%) (p = 0.05), simvastatin (31.5%), pravastatin (24.2%), fluvastatin (26.3%) or lovastatin (24.9%) (p < 0.0001). Rosuvastatin users were significantly more likely to attain LDL-C goal than those taking the other statins (odds ratio: 0.44, 0.28, 0.14, 0.14, 0.19, respectively; p < 0.001). Predicted percent attaining goal was significantly greater for those taking rosuvastatin (87.3%) than for those taking atorvastatin (76.9%), simvastatin (68.7%), pravastatin (55.0%), lovastatin (55.3%) or fluvastatin (61.3%) (p < 0.001). CONCLUSION: For diabetic patients, rosuvastatin is more effective at reducing LDL-C levels and attaining NCEP ATP III LDL-C goal than other statins in real-world clinical practice.

Cost and effectiveness analysis of immunization service delivery support in Andhra Pradesh, India.

The immunization service delivery support (ISDS) model was initiated in Andhra Pradesh, India, in November 2003 with the aim of strengthening immunization services through supportive supervision. The ISDS model involves a well-established supervision system built upon the existing health infrastructure. The objectives of this approach are to: (1) identify areas of high performance and those that need improvement, (2) assist staff in identifying and correcting wrong practices, (3) improve staff skills, (4) motivate staff, and (5) initiate corrective actions at appropriate levels through information sharing. An evaluation of cost and effectiveness of ISDS in 16 districts that participated in the programme found that the incremental cost associated with three rounds of supportive supervision visits was approximately US$ 110,630 (US$ 36,877 per round). The performance of health centre and immunization sessions was evaluated using 43- and 28-point checklists, respectively, and demonstrated significant improvement during and following the two-year implementation of ISDS. The average percentage change in health centre performance scores from baseline to the fourth round of evaluation was approximately 36%, and immunization session performance scores increased by an average of 9%. The incremental costs per additional per cent increase in average health centre performance score and per additional per cent increase in average immunization session performance score over the evaluation period were estimated to be US$ 3091 and US$ 12,760, respectively. The incremental cost-effectiveness ratios are relatively sensitive to personnel and travel costs. Integration of ISDS into the Andhra Pradesh immunization system is projected to result in a 39% potential cost savings per round of supervision visit.

Low-density lipoprotein cholesterol (LDL-C) levels and LDL-C goal attainment among elderly patients treated with rosuvastatin compared with other statins in routine clinical practice.

BACKGROUND: Reducing low-density lipoprotein cholesterol (LDL-C) levels lowers the risk of consequences of cardiovascular disease. Research has confirmed these benefits in elderly patients. The 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (ie, statins) have long-standing proven efficacy in reducing levels of LDL-C and total cholesterol. OBJECTIVE: The goal of this study was to compare change in LDL-C from baseline and National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III LDL-C goal attainment in a population of elderly patients (aged > or =65 years) treated with rosuvastatin versus other statins in routine clinical practice. METHODS: This was a retrospective cohort analysis using medical and pharmacy claims data linked to clinical laboratory results from a large managed care health plan of commercial and Medicare Advantage members in the United States. Included were members aged > or =65 years who were newly treated with statins (index date) from August 1, 2003, through February 28, 2005. All subjects were continuously enrolled for 12 months preindex and > or =30 days postindex, with variable follow-up until therapy discontinuation or end of health plan eligibility. Based on NCEP ATP III guidelines, patients were grouped into risk categories with associated LDL-C goals. The primary outcomes were change in LDL-C from baseline and attainment of NCEP ATP III LDL-C goal among patients not at goal before starting therapy. Generalized linear modeling was used to assess percent change in LDL-C from baseline, controlling for covariates (including age, sex, NCEP risk level, medication possession ratio, preindex LDL-C value, days from index date to postindex LDL-C value, and number of preindex office visits for dyslipidemia). In the subset of patients not at goal before starting therapy, logistic regression was used to estimate the odds of individual patients on other statins reaching goal as compared with rosuvastatin and to produce predicted percent attaining LDL-C goal on individual statins. RESULTS: Of the 2227 elderly new users of statin therapy, 8.0% started on rosuvastatin, 38.9% started on atorvastatin, 3.0% on fluvastatin, 31.0% on lovastatin, 5.5% on pravastatin, and 13.6% on simvastatin. Females comprised 57.7% of the population, and the mean (SD) age was 73 (5.8) years (range, 65-94 years). The mean (SD) doses of rosuvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin were 10.65 (4.59), 16.0 (12.78), 66.31 (23.56), 27.38 (14.07), 32.86 (16.46), and 28.1 (26.2) mg, respectively. After controlling for covariates, rosuvastatin-treated patients had a 35.8% decrease in LDL-C from baseline, which was significantly greater compared with patients in the atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin (29.3%, 21.9%, 22.5%, 22.0%, and 24.9%, respectively; P < 0.05) groups. Atorvastatin (odds ratio [OR], 0.25; 95% CI, 0.12-0.52), fluvastatin (OR, 0.05; 95% CI, 0.02-0.14), lovastatin (OR, 0.10; 95% CI, 0.05-0.20), pravastatin (OR, 0.08; 95% CI, 0.03-0.20), and simvastatin (OR, 0.14; 95% CI, 0.06-0.30) were less likely to attain LDL-C goal compared with rosuvastatin (all, P < 0.001). Predicted percent attaining goal was 93.6% among rosuvastatin users, significantly greater than users of atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin (81.2%, 55.8%, 66.8%, 64.1%, and 72.8%, respectively; P < 0.05). CONCLUSION: In this elderly patient population, rosuvastatin was a more effective treatment for reducing LDL-C levels and attaining NCEP ATP III LDL-C goals than the other statins.