Experience of a medicines reference-pricing model.

OBJECTIVE: To measure the impact of a medicines reference-pricing programme covering items for which appropriate generic equivalents are available. DESIGN: The list of covered items was continuously monitored and updated by clinicians and pharmacists employed by Medscheme, and was published as the Medscheme Price List (MPL). Prospective and retrospective analyses of prices of medicines covered by the MPL were carried out and the effect of the programme on expenditure by medical schemes was measured. RESULTS: The programme had an immediate effect on the rate of medicines inflation after implementation as a result of switching from original or branded products to generic medicines or switching from higher-priced to lower-priced generic equivalents. CONCLUSION: Over the past few years Managed Care has focused on strategies aimed at reducing utilisation of health care services and/or benefits by members of medical schemes. These strategies have largely been directed at members and health care providers, with little attention paid to suppliers (e.g. the pharmaceutical industry). This study has shown that a supplier-directed strategy has merit and is capable of substantially reducing expenditure on medicines.

Monitoring and management of bone status in patients on chronic glucocorticoid treatment--the Medscheme experience.

OBJECTIVE: Review of administrative databases to gain insight into the investigation, management and sequelae of bone disease in patients on long-term glucocorticoid treatment. DESIGN: Retrospective analysis of 1998 pharmaceutical and clinical claims data for +/- 2 million lives administered by Medscheme. Data were extracted for members registered with the chronic medication programme as eligible for chronic glucocorticoid treatment. Those identified were subjected to further review for evidence of osteoporosis and/or hip fracture. Subgroup analysis of peri- and postmenopausal women was carried out and compared against a control group. MAIN OUTCOME MEASURES: Osteoporosis investigation and treatment rates in males and females; frequency of hip fractures; prescribing profiles; role of underlying disease, glucocorticoid route, gender and age in development of osteoporosis. RESULTS: A total of 1,614 subjects (54% females) was registered for chronic glucocorticoid treatment. Osteoporosis was diagnosed in 14.1% of females and 5.9% of males across a broad age range. Hip fractures were recorded for one female and three males. The subgroup analysis showed that osteoporosis was +/- 1.5 times more common in women receiving glucocorticoids than in peri- and postmenopausal controls, and that there was greater use of vitamin D and calcium supplementation and bisphosphonates in those exposed to glucocorticoids. Multivariate analysis showed overall that female gender, increasing age and oral glucocorticoids were significantly related to osteoporosis. CONCLUSION: Reference to UK and US data suggests that while local practitioners are aware of the effect of glucocorticoids on bone, the level of awareness is probably suboptimal, especially with regard to male patients.

Perimenopausal wrist fracture--an opportunity for prevention and management of osteoporosis.

OBJECTIVE: Review of Medscheme's administrative databases to study the relationship between hip fracture and previous wrist fracture in peri- and postmenopausal women. DESIGN: Retrospective analysis of 1995-1998 data for women aged 50 and above hospitalised for management of wrist fracture. Those identified were subjected to further review to establish rates of osteoporosis and/or hip fracture. Osteoporosis and/or hip fracture rates were also determined for a control population. MAIN OUTCOME MEASURES: Osteoporosis investigation and management rates in controls v. subjects who had experienced a previous wrist fracture. RESULTS: A total of 701 subjects was admitted to hospital for management of a wrist fracture between 1995 and 1998; and compared with 1,385 similarly aged controls. Diagnosis of osteoporosis and admission for hip fracture were more common in women who had experienced a previous wrist fracture (relative risk (RR) 1.55; 95% confidence interval (CI) 1.19-2.03 for osteoporosis, and RR 3.32; 95% CI 1.16-9.69 for hip fracture). Of 10 hip fractures which occurred in the wrist fracture group, 9 were in women not diagnosed as having, or treated for, osteoporosis. CONCLUSION: While women with a history of wrist fracture are more likely than controls to be tested and treated for osteoporosis, it nevertheless appears that insufficient attention is being paid to this premonitory event.

A review of selection criteria used by medical scheme advisers to approve or deny procedures with a cosmetic component.

OBJECTIVE: To review and apply statistical tests to the selection criteria used by two medical advisers to approve or deny applications for three common cosmetic or reconstructive procedures within a large group of medical schemes. DESIGN: A retrospective descriptive study which applied multiple regression analysis, frequency analysis, comparison of means and simple correlations to the data sets for three procedures. SETTING: Administrative records from the clinical files of medical advisers and the administrator's claims database. SUBJECTS: Data were reviewed for 1,143 members who, between January and December 1996, submitted applications for breast reduction, excimer laser refractive surgery, or otoplasty. MAIN OUTCOME MEASURES: The primary outcome measure was the statistical relationship between medical advisers' selection criteria and final decision. In addition, the financial implications of these cosmetic/reconstructive procedures were assessed. RESULTS: For the three procedures reviewed there was a statistically significant relationship between 5 of 13 preoperative criteria requested and the medical advisers' opinion. Excimer laser surgery was generally approved on the basis of the refractive error (myopia > -3.00; astigmatism > -1.5 dioptres); otoplasty was generally approved for children aged > or = 12 years; and breast reduction was usually covered for women with a sternal-nipple distance > 29.0 cm and with a cup size > or = DD. The other data submitted were similarly distributed between the approved and denied groups. CONCLUSIONS: Review of medical advisers' decisions is important in an era of protocols, guidelines and 'standard operating procedures'. Selection criteria for approval of applications for medically necessary cosmetic/reconstructive surgery must be reviewed and revised to provide a reliable, reproducible and statistically valid process.

Formulary and funding implications of the gap between the national Essential Drugs List and current prescribing in a large health maintenance organisation.

BACKGROUND: The Department of Health has prepared an Essential Drugs List (EDL) for public sector implementation in 1996 and future extension to the private sector. Stakeholders have been consulted to ensure that the EDL achieves its objectives of safety, efficacy and quality at the lowest possible cost, while providing coverage for 90-95% of the common and important conditions in the country. This study was undertaken to gain insight into the current use of EDL products by 200 general practitioners (GPs) servicing a large health maintenance organisation (HMO). METHODS: Approximately 120,000 prescriptions were reviewed and the use of specified EDL medicines, other forms of EDL medicines and non-EDL medicines was analysed for several pharmacological groups. These included antibiotics and medicines for the cardiovascular, musculoskeletal, central nervous, respiratory and gastro-intestinal systems. To gauge potential savings to the private sector through the purchase of EDL products at state tender prices, current prices of a random sample of EDL products were compared. RESULTS: In the areas reviewed, only 22.4% of current GP prescriptions included EDL items; a further 19.6% included 'other forms of EDL' items. Simply obtaining those EDL products that are currently prescribed at state tender prices would reduce costs by almost 20%, while extending the use of EDL products might save in excess of 70% on private sector GP prescriptions. CONCLUSIONS: Assuming that all prescriptions were clinically indicated, the 'gap' between the EDL and medicines prescribed indicates that debate will be.

Analysis of paediatric prescribing profiles in two health-funding systems.

OBJECTIVE: To investigate the adequacy of two large South African medical administrative databases in providing prescribing profiles for paediatricians and general practitioners (GPs) respectively. DESIGN: Statistical analysis of data captured during 1994. Data were analysed retrospectively with frequency analysis and non-parametric tests. SETTING: Two industry databases, one covering a prepaid health maintenance organisation (HMO), the other providing a chronic medication programme for medical schemes and their members. MAIN OUTCOME MEASURES: Comparison of prescribing profiles of specialists and GPs. MAIN RESULTS: Data from the HMO revealed that referrals to paediatricians were mainly for gastro-intestinal and respiratory problems. Paediatricians' prescriptions for treatment of gastro-oesophageal reflux and/or abdominal pain represented 15.5% of all items prescribed and accounted for 40.7% of total paediatric medicine costs. GPs used formulary items more frequently, and cost per prescription was two-thirds that of specialists. Data from the chronic medication programme were used to compare treatment of asthma by the two provider groups. There were significant differences in the prescribing profiles of the two groups, with specialists using more in the way of "third-line agents' and newer, expensive products. Significant numbers of prescriptions did not conform to national guidelines for treatment of asthma. CONCLUSIONS: Industry databases provide a viable and valuable source of information; however, some problems were experienced in extracting the required data. Prescribing profiles revealed certain practices that require review, in particular the relatively low use of generic products, the early resorting to drug therapy for gastrooesophageal reflux, and non-conformity with national guidelines for management of childhood asthma.

Is registrarship a different experience for women?

OBJECTIVE: To determine differences between male and female registrars in their subjective perceptions and experience of a paediatrics registrar training programme. DESIGN: Cross-sectional survey. SETTING: University-affiliated teaching hospitals. PARTICIPANTS: Thirty-nine paediatrics registrars. RESULTS: Of the 39 respondents, 18 (46%) were women. Men were older than women (30.4 v. 29.1 years, P = 0.049). There were no gender differences in the number of hours worked per week (65.7 v. 67.8 hours, P = 0.384) or participation in the training programme. Success rates in postgraduate paediatrics examinations were also similar for the two groups (85% v. 76% P = 0.486). Male registrars were more likely to have 'moonlighted' (43% v. 6%, P = 0.011). Fifty-nine per cent of female registrars believed that they had been disadvantaged in their careers because of their gender, 28% felt that more was expected of a woman registrar and 22% of the female trainees claimed to have been subjected to sexual harassment. The majority (82%) of women registrars contemplated taking time off from practising clinical paediatrics in the future (post-registrarship), mainly for child-bearing purposes. Female respondents criticised both the academic department and the hospital authorities for discriminatory practices, such as the awarding of home loans to men and women who were breadwinners only. The findings suggest that women registrars do feel disadvantaged and discriminated against, and highlight the need for flexible, creative programmes that recognise the needs and aspirations of female registrars and, indeed, all women in academic medicine.

Bacteraemia in malnourished rural African children.

During a 5-month study period, 323 of 863 (37.5%) children below 5 years of age admitted to Shongwe Mission Hospital in rural South Africa were malnourished, two-thirds severely so. The incidence of bacteraemia in malnourished children was 9.6%, 11.8% in those severely malnourished and 5.8% in nutritional dwarfs. The predominant organisms retrieved were Gram-negative enteric bacilli (48.5%). Amongst the severely malnourished, who empirically receive intravenous ampicillin and gentamicin, 95.8% of all isolates were sensitive to this antibiotic combination. The case fatality rate of severely malnourished bacteraemic children was 20.8%. In malnutrition categories overall, the case fatality rate for bacteraemic children (22.6%) was significantly greater than in those without bacteraemia (9.3%). In hospitals with limited resources, full identification of bacteria may not be necessary, provided that regular surveillance for emerging resistance is conducted.

PIP: There are an estimated 170 million children in the world who are malnourished, 20 million severely. The authors determined the prevalence of bacteremia in malnourished children admitted to Shongwe Mission Hospital, documented the effect of bacteremia upon mortality, and provide a basis for antimicrobial use in malnourished children with suspected bacteremia. 323 of 863 children under age 5 years admitted to the hospital between May 23 and October 22, 1992, were malnourished, 66% severely. There was a 9.6% prevalence of bacteremia in malnourished children, 11.8% in those severely malnourished, and 5.8% in nutritional dwarfs. Gram-negative enteric bacilli were retrieved in 48.5% of cases. 95.8% of all isolates among the severely malnourished children were sensitive to the combination of intravenous ampicillin and gentamicin. There was a 20.8% case fatality rate among severely malnourished bacteremic children. In malnutrition categories overall, the case fatality rate for bacteremic children (22.6%) was significantly greater than in those without bacteremia (9.3%). The authors note that it may not be necessary to fully identify bacteria in hospitals with limited resources as long as regular surveillance for emerging resistance is conducted.

Determinants of blood pressure in Sowetan infants.

A study of the effect of different variables on the blood pressure of Sowetan infants was undertaken with the Birth-to-Ten (BTT) cohort as the study population. Variables studied at 1 year included anthropometric indices, aspects of feeding practices and relationship to maternal blood pressure. Systolic blood pressure was recorded in 792 infants at 1 year; 29,3% of the variance was determined by weight, upper arm circumference, age at which formula feeds were started, length and volume of formula feeds (in order of significance). Amount of salt added to diet approached statistical significance. Data available for 353 of the 752 infants showed a correlation between the infants' and the mothers' blood pressure. The maternal blood pressure only accounted for an additional 2% of the variance; approximately 70% of blood pressure variance is therefore still unexplained. Firm recommendations with regard to use of formula feeds and the addition of salt to infants' diet are difficult to make on the basis of this limited follow-up.

Selection of paediatric patients for intensive care.

OBJECTIVES: To determine characteristics of older infants and children admitted to the paediatric intensive care unit (PICU) at Johannesburg Hospital; and to evaluate an admission score based on the PRISM score (an index of severity of illness) as a possible means for selection of patients for admission to the PICU. DESIGN: Retrospective review of patient records and calculation of admission score from data. SETTING: Paediatric intensive care unit at Johannesburg Hospital. SUBJECTS: All patients older than 3 months of age admitted to the PICU from July 1993 to 31 March 1994. RESULTS: There were 117 admissions during the study period with a mean age of 4,6 years. The mortality rate was 29.1%. The mean duration of ICU stay was 4,2 days. A review of requests for admission showed that over a 7-month period, 53 patients (> 3 months) could not be accommodated. In 71 patients with complete data, the admission score was significantly higher in non-survivors than survivors. The area under the ROC curve for predicting mortality from the admission score was 0.73 (SE 0.054). An admission score > or = 16 predicted mortality with a sensitivity of 42% and a specificity of 98%. CONCLUSIONS: PICU facilities at Johannesburg Hospital are insufficient to meet the demand. An admission score based on the PRISM score could assist in the selection of patients for these limited PICU facilities.

Reasons for failure to administer antenatal corticosteroids in preterm labour.

A retrospective review of 101 preterm infants delivered at Johannesburg Hospital was conducted to determine the use of antenatal corticosteroids (ACs). Overall there were 38 opportunities for the use of ACs of which 18 were missed. Of the remaining mothers, 32 presented in advanced labour, 22 presented with obstetric emergencies and 6 were managed as inevitable abortions. There was a significant association between lack of antenatal care and presentation in advanced labour. Therefore, although only 20% of mothers received ACs, there was no opportunity for their use in the majority of patients. The use of a safe and cost-effective measure such as ACs should not be ignored in a country with limited health resources. Better antenatal care as well as increased awareness among obstetricians is required to improve the situation.

The introduction of surfactant replacement therapy into South Africa.

Within the context of limited financial and physical resources in South Africa, academic neonatologists have established strict criteria for ventilation of neonates with hyaline membrane disease (HMD). In the private sector neonatal care is less structured. Following the introduction of the artificial surfactant (Survanta) in November 1991 it was considered important to monitor its use in the public and private sectors. In collaboration with the marketing company a data sheet containing demographic information and clinical details was drawn up to be completed in each case where Survanta was administered to babies with HMD. Data from 155 babies treated at 10 hospitals were included in the final analysis (70 babies from 4 State-funded academic hospitals and 85 from 6 privately funded hospitals). Within the group of private hospitals there were some which treated large numbers of babies weighing > 2,000 g, while in a few others there was a relative excess of babies weighing < 1,000 g. There was a higher incidence of patent ductus arteriosus and intraventricular haemorrhage, and a higher mortality rate at the academic hospitals. Poor outcome at these institutions may largely have been due to poor antenatal care.

The selection of infants for surfactant replacement therapy under conditions of limited financial resources.

The cost of surfactant replacement therapy (SRT) will restrict its use under conditions of limited health resources. Before the local advent of SRT, infants ventilated for hyaline membrane disease (HMD) had an overall survival rate of 87% and an incidence of bronchopulmonary dysplasia of 6.4%. This, together with the cost of SRT, prompted a study to identify those infants who would benefit the most from SRT. Twenty-two infants assessed as having severe HMD were randomised to receive SRT at 3 - 4 hours (9) or at 6 - 8 hours (13) after birth. Two infants (15%) in the latter group did not require SRT. The outcome of these two groups was the same. Of 56 infants assessed as having moderate HMD, only 24 (43%) qualified for SRT from 6 hours of age. The outcome of the SRT and non-SRT infants was comparable. The group of infants with moderate HMD had a significantly better outcome than those with severe HMD. A limited period of observation to assess the severity of illness did not compromise outcome in this group of 78 infants with moderate to severe HMD.

The cost and effectiveness of surfactant replacement therapy at Johannesburg Hospital, November 1991-December 1992.

OBJECTIVE: To assess the impact of surfactant replacement therapy (SRT) on the outcome of hyaline membrane disease (HMD) and to assess the cost implications of a policy of selective administration of artificial surfactant. DESIGN: The short-term outcome of 103 newborns ventilated for HMD (61 selected for SRT according to initial and/or ongoing oxygen requirements) was compared with that of a historical control group of 173 infants ventilated for HMD before the introduction of SRT. MAIN OUTCOME MEASURES: Mortality and morbidity of HMD including death, bronchopulmonary dysplasia, pneumothorax, pulmonary haemorrhage, patent ductus arteriosus and intraventricular haemorrhage. RESULTS: There were significant demographic differences between the treatment and control groups (black patients 74% v. 28%, P < 0.0001; unbooked mothers 72% v. 15%, P < 0.0001) as well as evidence of more severe lung disease in the treatment group (pressor support 44% v. 27%, P < 0.005; and paralysis during ventilation 38% v. 25%, P < 0.005). Pneumothorax was reduced in the SRT group (7% v. 17%, P < 0.01). There were no significant differences between the two groups in the incidence of BPD or mortality. The use of SRT added to the total cost of treating a patient ventilated for HMD. CONCLUSION: The selective use of SRT had the effect of converting severe disease into moderate disease rather than achieving maximal benefit in all cases of HMD through routine use of the product. A policy of restricting use may result in cost savings where resources are limited.