Genetic testing in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cost-effectiveness analysis.

BACKGROUND: The CYP2C19 genotype is a predictor of adverse cardiovascular events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) treated with clopidogrel. OBJECTIVES: We aimed to evaluate the cost-effectiveness of a CYP2C19*2 genotype-guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared with two 'no testing' strategies (empiric clopidogrel or prasugrel). METHODS: We developed a Markov model to compare three strategies. The model captured adverse cardiovascular events and antiplatelet-related complications. Costs were expressed in 2010 US dollars and estimated using diagnosis-related group codes and Medicare reimbursement rates. The net wholesale price for prasugrel was estimated as $5.45 per day. A generic estimate for clopidogrel of $1.00 per day was used and genetic testing was assumed to cost $500. RESULTS: Base case analyses demonstrated little difference between treatment strategies. The genetic testing-guided strategy yielded the most QALYs and was the least costly. Over 15 months, total costs were $18 lower with a gain of 0.004 QALY in the genotype-guided strategy compared with empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared with empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared with wild-type individuals treated with clopidogrel. Above a 47% increased risk, a genotype-guided strategy was the dominant strategy. Above a clopidogrel cost of $3.96 per day, genetic testing was no longer dominant but remained cost-effective. CONCLUSIONS: Among ACS patients undergoing PCI, a genotype-guided strategy yields similar outcomes to empiric approaches to treatment, but is marginally less costly and more effective.

Creating change agents: a national substance abuse education project.

OBJECTIVE: This study evaluated the effects of a national interdisciplinary faculty development program, Project MAINSTREAM, on creating curriculum enhancement in health professional education. METHOD: Thirty-nine faculty completed a two-year, part-time fellowship program featuring interdisciplinary collaboration, mentoring, training meetings, and Internet-based instructional materials. The main vehicle for curricular change was a required collaborative education project to develop trainees' core competencies in substance abuse prevention services. RESULTS: Fellows used a variety of approaches to implement 123 curricula and provide 66,995 hours of training to 10,170 trainees. Ninety percent of the training hours occurred in required courses, a potential indication of sustainability. Fellows indicated that a majority of the offerings would be sustained beyond the fellowship. CONCLUSION: Project MAINSTREAM shows promise as a model for achieving durable curriculum change in response to the public health crisis associated with a workforce untrained to deliver substance abuse services.

Interdisciplinary service-learning substance abuse projects: processes and outcomes.

The purpose of this paper is to describe the development and implementation of community-based, service-learning field projects by 30 health professional faculty fellows of Project MAINSTREAM, a faculty development program on substance abuse. The fellows worked together for two years in 10 Interdisciplinary Faculty Learning Groups (IFLGs), which consisted of three academics of different disciplines. The ten projects are viewed within the context of service- learning and are based on a balance between the provision of services to the community and furthering the learning objectives of Project MAINSTREAM.