Economic outcomes of antipsychotic agents in a Medicaid population: traditional agents vs. risperidone.

Clinical trials reveal that the newer atypical antipsychotic agents are more effective and have fewer side effects than traditional agents. However, these newer agents have a higher acquisition cost than traditional agents. This study assessed the differential impact of risperidone and traditional agents on the total schizophrenia-related cost of care for Medicaid patients suffering from schizophrenia. This was a retrospective longitudinal pretest-posttest analysis of Medicaid claims data covering January 1992 to August 1996. Continuously eligible patients (n = 150) with a documented diagnosis of schizophrenia were evaluated. Medical claims were analyzed for patients treated with traditional antipsychotics for at least 12 months and then switched to risperidone and followed for at least 12 months. Patients who failed on at least one traditional agent and who remained on other traditional agents throughout the study timeframe served as a control group. Monthly costs per patient were estimated using mixed model linear regression with age and gender serving as covariates. The total monthly costs per patient for the risperidone and traditional cohorts were similar ($1,050.52 and $946.24, respectively; p = .5438) during the pretest phase of the study. For patients treated with risperidone, drug costs were $177.35 higher (CL0.95 +/- $7.64; p = .0001) per patient per month in the posttest period compared with the pretest period. However inpatient hospital costs were $312.04 lower (CL0.95 +/- $146.76; p = .001) per patient per month in the posttest period compared with the pretest period. In addition, physician costs were $9.55 lower (CL0.95 +/- $5.31; p = .0004) per patient per month in the posttest period. The difference from the pretest to posttest period for outpatient mental health clinic costs was statistically similar. For those in the risperidone cohort, total estimated costs decreased by $204.87 per patient per month during treatment with risperidone (CL0.95 +/- $161.01; p = .0127). Over the same time-frame, total costs increased $160.68 per patient per month (CL0.95 +/- $196.04; n.s.; p = .1082) in the control cohort. While the mean monthly drug cost was significantly higher during treatment with risperidone, this increase was offset by cost reductions elsewhere in the system.

Long-term patient compliance with prescribed regimens of calcium channel blockers.

Patient compliance with drug therapy is an important component in the successful management of chronic diseases. The objective of this study was to determine the mean compliance ratio for calcium channel blocking agents in a 2-year study of prescription claims records. The effect on compliance relating to the number of daily doses, length of drug therapy, therapeutic use, and patient age also was investigated. We analyzed prescription drug claims records from an insurance program with prescription drug benefits for state employees, teachers, and retirees in the state of Oklahoma. A total of 105,559 calcium channel blocker prescription claims representing 9807 treatment regimens were made between July 1990 and June 1992. A stratified random sample of 2377 treatment regimens was drawn from this population. The mean compliance ratio for all patients was 78.22%. The number of daily doses and the length of the treatment regimen were significant factors in the compliance model (P = 0.0001). The age of the patient was not significant. Differentiating therapeutic use by symptomatic (angina pectoris) or nonsymptomatic (hypertension) indications also was not significant. Once-daily treatment regimens were found to provide the highest mean compliance ratio (84.86%). This was followed by twice-daily administration, with a mean of 79.88%; three times daily, 75.16%; and four times daily, 73.06%. Multiple comparisons analysis indicated a statistically significant difference between each dosing regimen with the exception of three-versus four-times-daily administration. The highest mean compliance ratio (101.51%) was found with treatment lengths of 2 months. The mean compliance ratio declined as the length of therapy increased. The decline in patient compliance was most pronounced with treatment lengths between 2 and 4 months. The mean compliance ratio was lowest for treatment lengths of 16 months (71.00%), although there was no significant difference between treatment lengths of 6, 12, 16, or 20 months. The deterioration of compliance over time ceased with treatment lengths exceeding 16 months. Based on these data, prescribers should attempt to minimize or simplify the frequency of the dosing regimen when possible. Discussions with the patient involving medication compliance may be of greater value during follow-up visits with the physician or pharmacist when noncompliant behavior becomes most pronounced.

Practical tips for assessment and management of vulvar and vaginal human papillomavirus.

Human papillomavirus (HPV) infection has been strongly associated with intraepithelial neoplasia and cancers of the lower genital tract. Due to either better detection or increased incidence of this infection, there is a greater demand for colposcopy. Historically, clinicians have focused their colposcopic investigation on the cervix, often neglecting evaluation of the vulva and vagina. Because HPV is a multicentric disease, these areas should not be overlooked. Nurse colposcopists need to assess and manage women who have HPV-related vulvovaginal lesions that are either symptomatic or have the potential to advance to cancer.

Stochastic resonance in a single neuron model: theory and analog simulation.

Here, we consider a noisy, bistable, single neuron model in the presence of periodic external modulation. The modulation induces a correlated switching between states driven by the noise. The information flow through the system, from the modulation, or signal, to the output switching events, leads to a succession of strong peaks in the power spectrum. The signal-to-noise ratio (SNR) obtained from this power spectrum is a measure of the information content in the neuron response. With increasing noise intensity, the SNR passes through a maximum: an effect which has been called stochastic resonance, and which was first advanced as a possible explanation of the observed periodicity in the recurrences of the Earth's ice ages. We treat the problem within the framework of a recently developed approximate theory, valid in the limits of weak noise intensity, weak periodic forcing and low forcing frequency, for both additive and multiplicative noise. Moreover, we have constructed an analog simulator of the neuron which demonstrates the stochastic resonance effect, and with which we have measured the SNRs for comparison with the theoretical results. Our model should be of interest in situations where a single inherently noisy neuron is the receptor of a periodic signal, which is itself noisy, either from the network or from an external source.

Noise effects in an electronic model of a single neuron.

We consider a simple electronic circuit model of a single neuron. The neuron is assumed to be driven by an external signal comprising constant (dc) and random components. In addition, the nonlinearity parameter in the circuit is assumed to fluctuate, thereby giving rise to critical behavior including the onset of hysteresis phenomena even for system parameter values that would not otherwise support such behavior. This "noise-induced critical behavior" is analysed, in the long time limit, through a study of the probability density function describing the neural response.

Professional attitudes of Ohio pharmacists working in three practice settings.

The attitudes of pharmacists in three practice settings toward a set of attributes associated with professionalism were studied. A questionnaire that included the 40-item Shack and Hepler professionalism instrument was mailed to 1999 pharmacists in Ohio. Responses from 617 pharmacists who worked in hospital, independent community, or chain community pharmacy practice were used. There were significant differences between the responses of pharmacists who worked in the different practice settings (multivariate analysis of variance, p less than 0.01). However, the practice setting accounted for less than 10% of the variance in the responses. Statistically significant differences were also observed when the pharmacists were grouped according to sex, years since graduation, degree, and job position; however, less than 8% of the variance in the responses could be explained by the demographic variables. There did not appear to be any practical differences in beliefs about professional attributes among pharmacists working in hospital, independent community, and chain community practice settings.

Acceptability of cholestyramine or colestipol combinations with six vehicles.

Preferences for cholestyramine or colestipol in combination with orange drink, orange juice, grape juice, apple juice, water, or apple sauce were evaluated in 40 healthy adults. Each subject evaluated the taste, texture, and smell of 30-mL samples of 12 drug-vehicle combinations (two drugs, six vehicles) using modified five-point wine-tasting scales. Samples were prepared to contain either cholestyramine 1.0 g or colestipol hydrochloride 1.3 g. The products were tested at room temperature and were administered in a random order. Subjects and observers were blinded to the identity of the products. Acceptability scores for taste, texture, and smell were significantly higher for cholestyramine than for colestipol. Total mean preference scores for cholestyramine-vehicle combinations ranged from 9.9 to 11.7; for colestipol, 6.3 to 8.9. Orange drink, apple juice, grape juice, and orange juice were the preferred vehicles for cholestyramine. The preferred vehicles for colestipol were orange drink, apple sauce, and apple juice.

Reconstruction of a large chest wall defect using greater omentum.

A 56-year-old woman was admitted for treatment of a large carcinoma that involved the chest wall. Fourteen years earlier, she had undergone a radical mastectomy, which was followed by chemotherapy and radiation therapy. The carcinoma was excised and the large anterior chest wall defect reconstructed using Marlex mesh, an omental pedicle flap, and a split-thickness skin graft.