Linking the health utilities index to National Medical Expenditure Survey data.

Measures of health-related quality of life (HR-QOL) are becoming increasingly important in assessing the effects of chronic illness and healthcare interventions designed to treat them. Obtaining measures of HR-QOL for a nationally representative sample of individuals would enhance understanding of health status in the US, and promote further study of the economic causes and effects of health status. This study reports on our efforts to link a prominent HR-QOL scale, the Health Utilities Index Mark I (HUI), to the National Medical Expenditure Survey (NMES). Six distinct algorithms were constructed for linking the HUI to NMES. These alternative linkage algorithms yielded HUI measures that were highly intercorrelated (p = 93 to 99%). Multivariate regression analyses performed to predict variations in HR-QOL revealed that the HUI exhibited good predictive validity--the HUI demonstrated lower quality of life for a variety of chronic illnesses, and wealthier individuals and better educated individuals had a higher quality of life. In contrast to some previous HR-QOL research, the present analysis demonstrates that: (i) cancer is negatively and significantly related to quality of life; and (ii) smoking is negatively and significantly related to quality of life. Overall, the results suggest that the HUI linkages to NMES provide reliable and valid measures of quality of life. As such, items from the NMES can be grouped and linked in such a way as to obtain health state utility values. These values should be of use to those who wish to understand the global health of the US population for policy-making efforts.

Randomized trial comparing the tolerability of sargramostim (yeast-derived RhuGM-CSF) and filgrastim (bacteria-derived RhuG-CSF) in cancer patients receiving myelosuppressive chemotherapy.

A prospective, randomized, double-blind, multicenter study in cancer patients receiving myelosuppressive chemotherapy was undertaken to evaluate and compare the tolerability of sargramostim (yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor, RhuGM-CSF) and filgrastim (bacteria-derived recombinant human granulocyte colony-stimulating factor, RhuG-CSF) in the prophylaxis or treatment of chemotherapy-induced neutropenia. In all, 137 evaluable patients received sargramostim (300 micrograms; 193 mg/m2) or filgrastim (481 mg; 7 mg/kg) once daily by self-administered s.c. injection, usually beginning within 48 h after completion of chemotherapy. With the exception of a slightly higher incidence of grade 1 fever (< 38.1 degrees C) with sargramostim, there were no statistically significant differences in the incidence or severity of local or systemic adverse events possibly related to the growth factors. Although the study was not designed to evaluate efficacy directly, there also were no statistically significant differences between treatment groups in total days of growth factor therapy, days of hospitalization, or days of i.v. antibiotic therapy during the treatment period. Both sargramostim and filgrastim were comparably well tolerated when given by s.c. injection in this group of patients, and no clinically significant differences between the growth factors were demonstrated.

Death rates among patients hospitalized with community-acquired pneumonia: a reexamination with data from three states.

OBJECTIVES: Death rates for community-acquired pneumonia based on relatively small-scale, published studies tend to exceed 15% to 20%. This study reexamined these estimates by using very large, population-based databases. METHODS: Death rates from 1993 associated with community-acquired pneumonia were reexamined with hospital discharge data from all of Washington, Illinois, and Florida. RESULTS: These death rates were substantially lower (7.0%, 8.1%, and 9.7%, respectively) than what appears in the literature. Significant risk factors for dying were being 65 years of age or older (odds ratio [OR] = 2.9), being positive for human immunodeficiency virus (OR = 2.9), and having a high severity of illness (OR = 7.1). CONCLUSION: Sampling bias associated with selection for hospital admissions explain the discrepancy between previous and this study's results.

Labour productivity effects of prescribed medicines for chronically ill workers.

Previous work on the labour productivity effects of chronic illness has not separated the effects of chronic illnesses from the effects of prescription medications taken to alleviate these conditions. Using nationally representative observational data, this study estimates the pure effect of chronic illness, and the marginal effect of prescription medicines, on labour productivity. As Americans continue to scrutinize health care expenditures, such estimates will play an increasing role in determining the allocation of resources for medical treatments. Estimates are presented of the costs and benefits to employers of covering prescription medications for workers aged 18-64 years afflicted with specific chronic illnesses. The effects of prescription medicines on hourly wages and days lost from work are examined for four major chronic illnesses: hypertension, heart disease, non-insulin dependent (type II) diabetes and depression. The net benefits to employers from having workers take prescription medicines for their chronic illnesses are substantial. Assuming average compliance rates are achieved, net benefits to employers in 1987 amounted to $286 per hypertensive employee, $633 per employee with heart disease; $822 per depressed employee, and $1475 per type II diabetic employee under medication from a physician. These estimated benefits accrue because prescription medications substantially lower absenteeism among chronically ill workers.

Rate of exposure to theophylline-drug interactions.

Many drugs have been shown to interact adversely with theophylline, including ciprofloxacin, verapamil, and cimetidine. These drug interactions may have serious results such as seizures, circulatory failure, and respiratory arrest, which may require hospitalization. Thus interactions should be prevented. This study was conducted to help understand the degree to which patients taking theophylline are exposed to the potential risks of theophylline toxicity. Detailed diagnostic, demographic, and health care utilization data were obtained from the Pennsylvania Medicaid Management Information System computer files on patients who filled at least one prescription for any theophylline-containing drug between October 1, 1991, and December 31, 1992, and whose prescriptions for theophylline extended into 1992. The outcome measure of interest in this analysis was the rate at which patients were exposed to potential theophylline interactions, defined as the percentage of time that a patient was taking theophylline that he or she was also prescribed another drug known to interact adversely with theophylline. A total of 17,933 patients met the study criteria. On average, patients included in the analysis received theophylline for 121.3 out of 365 days in 1992. When the theophylline-interacting drugs were examined in the aggregate, 6619 patients (36.9%) were prescribed at least one of the drugs concomitantly with theophylline, for an average duration of 70.4 days of exposure. The overall rate of exposure to potential theophylline-drug interactions was 17.8%. These findings indicate that patients taking theophylline are exposed to adversely interacting drugs a significant proportion of the time that they are receiving theophylline. Clinicians should be made aware of this risk so that they may prescribe safer treatments that avoid this problem.

Use of non-antacid antiulcer agents in the treatment of heartburn and dyspepsia.

This study examined secondary-claims data to measure the cost of using non-antacid antiulcer agents to treat patients with heartburn or dyspepsia. Health care utilization data were obtained from the Pennsylvania Medicaid program. The study population comprised all enrollees with dyspepsia or heartburn, excluding those with a history of ulcers. The rate and cost of gastrointestinal-related outpatient services were examined for patients receiving antiulcer drug monotherapy. The mean age of the study population (n = 1830) was 39.1 years. Ranitidine patients (n = 856) received monotherapy for an average of 71.1 days. Cimetidine (n = 395) and famotidine (n = 255) patients received monotherapy for an average of 65.0 and 71.7 days, respectively. (Mean duration of monotherapy for the other four groups ranged from 58.0 to 112.6 days). On average, there were 0.83 prescriptions issued, 0.21 physician visits, and 0.23 outpatient hospital visits per patient-month across all treatment groups. The average cost to the Pennsylvania Medicaid program was approximately $68 monthly per patient. Drugs accounted for the majority of these costs ($51.04), followed by surgical/diagnostic procedures ($5.13), outpatient hospital visits ($4.89), and physician visits ($4.15).

Cost effectiveness of beractant in the prevention of respiratory distress syndrome.

Beractant, a modified natural bovine surfactant extract, has been used successfully in the prevention of respiratory distress syndrome (RDS) in premature neonates. This analysis investigates the cost effectiveness of prophylactic surfactant therapy. Resource utilisation data were analysed retrospectively from 210 patients who had participated previously in a double-blind, placebo-controlled clinical trial. No baseline differences were apparent between the beractant and sham-air control groups. There was a significant difference in survival favouring the beractant-treated neonates. When the acquisition cost of the study drug was excluded, there was an incremental, daily cost-savings benefit for the beractant-treated group compared with the sham-air treated group. Costs per case per day were significantly lower for neonates treated with beractant ($US1442 beractant vs $US1544 sham-air; 1991 dollars p = 0.01). Costs for radiological and diagnostic procedures, respiratory care and drugs (excluding beractant) were all significantly lower. When the acquisition cost of beractant was included, the cost to produce a 28-day survivor was $US3319 less with beractant ($US41 020) than with sham-air ($US44 339). Thus, when viewed in terms of costs per year of life saved, beractant compares very favourably with other recently evaluated health technologies.

Drug utilization review using a Medicaid claims database.

A methodology for conducting drug utilization review (DUR) using Medicaid claims data is presented. The DUR allows for calculation of rates and costs of health care utilization among patients with established diagnoses and specific drug regimens; for comparison of results between competing drug therapies; for quantification of the percent market share of pharmaceutical products; and for projection of the duration of a given drug therapy. The strengths and limitations of using Medicaid data for DUR are discussed.

Potential cost savings of oral versus intravenous etoposide in the treatment of small cell lung cancer.

An economic analysis was conducted on a randomised multicentre study comparing the use of intravenous (IV) etoposide versus oral etoposide treatment regimens in patients with small cell lung cancer. 41 patients received cisplatin 100 mg/m 2 intravenously (IV) on study day 1 and etoposide 120 mg/m 2 IV on study days 1, 2, and 3 (IV regimen); and 42 patients received cisplatin 100 mg/m 2 IV and etoposide 120 mg/m 2 IV on study day 1 and 240 mg/m 2 orally (equivalent to 120 mg/m 2 IV) on study days 2 and 3 (oral regimen). The results of the study from which these data were extracted showed equal efficacy between groups. Based on a retrospective review of resource use in the clinical trial, patient healthcare costs were examined in the following areas: antineoplastic drugs, IV fluids, supplies used for chemotherapy administration, and chemotherapy administration procedure fees. The total cost per course of therapy was $US2002 for the IV regimen and $US1653 for the oral regimen. This represented a 17% savings for patients receiving the oral regimen.

The cost-effectiveness of idarubicin/cytosine arabinoside versus daunorubicin/cytosine arabinoside in the treatment of adults with acute myeloid leukemia.

The cost-effectiveness of two chemotherapeutic regimens was evaluated from the results of a randomized clinical trial involving patients with previously untreated acute myeloid leukemia. The evaluable subjects were 120 patients with acute myeloid leukemia randomly assigned to receive 12 mg/m2 of idarubicin (IDA) or 50 mg/m2 of daunorubicin (DNR) daily for three days. The patients also received 200 mg/m2 of cytosine arabinoside daily for five days, with an additional 25-mg/m2 bolus on the first day of treatment, the patients underwent a second course at the same doses. The total hospital charges per patient were $59,687 for IDA treatment and $59,567 for DNR treatment; however, the cost per complete remission was lower in the IDA than in the DNR patients ($74,609 vs $102,115). The lower remission rate in the DNR-treated patients, and thus their need for additional care, will increase the cost differences between the two treatments. The hospital charges per year of survival were $36,395 for IDA treatment and $52,714 for DNR treatment. It is concluded that IDA is more cost-effective than DNR in the treatment of adult acute myeloid leukemia.

Posttraumatic stress disorder in World War II and Korean combat veterans with alcohol dependency.

Our country was confronted with the problems of postcombat adjustment while the Vietnam conflict was still winding down. Concerns centered on the disruptive impact of returning drug-dependent veterans, the overall problems of readjustment, and assessment of public attitudes. As is the case with each major conflict, health-care-delivery systems were forced to assess and react to the aftermath of combat. This took place within the framework of the disciplines of program evaluation, quality assurance, and clinically applied research. Out of this has evolved a determined attempt to understand the interaction between combat and psychiatric disorders including alcoholism. This chapter demonstrates the existence of a posttraumatic stress syndrome compounded by alcoholism in World War II and Korean Conflict veterans. These comorbidities have resulted in chronic maladjustment over a prolonged period of time. Recommendations suggest early detection and triage of a posttraumatic syndrome and co-related substance use disorder in people who experience any catastrophic stressor.

Extinguishing conditioned responses during opiate dependence treatment turning laboratory findings into clinical procedures.

Former opiate addicts (even those who have remained drug-free for several months) often report symptoms of opiate withdrawal (eg. nausea, gooseflesh, etc.) and/or intense drug craving when exposed to stimuli previously associated with the act of drug injection. This phenomenon of learned or "conditioned" withdrawal/craving is widely reported and is potentially important in explaining relapse to drug use. However, no effective, clinically applicable intervention had been available to "extinguish" these conditioned phenomena. An ongoing project to develop such an intervention has revealed: Conditioned withdrawal and craving are pervasive among both methadone maintained patients (even though actual physical withdrawal is blocked) and drug-free patients even after 30 days of inpatient Therapeutic Community rehabilitation. Conditioned withdrawal and craving can be effectively extinguished in an intensive, three-week, inpatient procedure. Emotional states such as anger, depression and anxiety can elicit and exacerbate conditioned withdrawal and craving. They may also act as an integral part of a conditioned stimulus complex. The authors discuss the problems associated with turning a laboratory-based procedure into a clinical intervention. Encouraging preliminary results from an integrated treatment "package" are presented.

Use of the catheterized rat in studies on social interactions and plasma catecholamines.

Catheterized rats were subjected to various social conditions and amphetamine treatment and plasma norepinephrine and epinephrine levels were measured. Normal interactions involving another male or female rat did not alter plasma catecholamine levels. Social interactions with a mouse or an amphetamine treated, hyperactive male rat had no effect on plasma epinephrine but increased norepinephrine levels significantly. A low dose of amphetamine given to the catheterized rat increased only plasma norepinephrine levels. The catheterized rat was found to be a very useful animal model for the study of social interactions and their effects on physiological processes as reflected in changes in certain blood chemicals.