Economic outcomes with antidepressant pharmacotherapy: a retrospective intent-to-treat analysis.

Herein we describe a retrospective intent-to-treat evaluation designed to compare the natural course of antidepressant utilization and direct health service expenditures for the treatment of a single episode of major depression among patients enrolled in a multistate network-model health maintenance organization and initially prescribed either a tricyclic antidepressant (amitriptyline or nortriptyline) or the serotonin selective reuptake inhibitor (SSRI) fluoxetine. Patient-level paid-claims data for the period July 1, 1988, through December 31, 1991, were abstracted. During the above time frame, fluoxetine was the only SSRI available in the United States. Patients prescribed amitriptyline were more than three times as likely to require a change in antidepressant pharmacotherapy (OR = 3.27, 95% CI = 2.31 to 5.49), while patients prescribed nortriptyline were nearly four times more likely to change medication (OR = 3.82, 95% CI = 2.74 to 6.83) relative to patients initially prescribed fluoxetine. Consistent with our intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate analyses revealed that initiation of antidepressant pharmacotherapy with amitriptyline resulted in a 25.7% increase in per capita depression-related health service expenditures per year, while initiation of antidepressant pharmacotherapy with nortriptyline resulted in a 28.1% increase in per capita depression-related health service expenditures per year relative to patients initially prescribed fluoxetine. A financial break-even point was achieved at the conclusion of Month 5, at which time all three intent-to-treat cohorts had comparable health service expenditures in total. From a financial perspective, results stemming from this inquiry suggest that the initiation of antidepressant pharmacotherapy with an SSRI is warranted.

Cost benefit of sumatriptan to an employer.

Benefit and occupational health managers need information on whether new treatments, such as sumatriptan, for migraine headache improve organizational or individual performance. A work productivity outcomes assessment was conducted among sumatriptan-using employees of an Independent Practice Association-health maintenance organization population. Of the 164 sumatriptan users, 101 full-time employees were surveyed by telephone once in an open-label, before-after design. The results revealed that lost labor costs, a function of days missed from work and reduced productivity at work as a result of migraine, were decreased after sumatriptan treatment initiation. Incremental benefit of this reduction in lost productivity is valued at $435/month per employee. The sumatriptan cost associated with this benefit is $43.78/month. The benefit-to-cost ratio is 10:1. Other costs and benefits were excluded. In conclusion, the availability of sumatriptan for migraine headache treatments in this IPA-HMO resulted in improved work productivity and had a net benefit for the employer.

Cost-effectiveness of sumatriptan in a managed care population.

We conducted an open-labeled study to determine whether sumatriptan is more cost-effective than other therapies used to treat migraine headache. We contacted by phone 220 sumatriptan users enrolled in QualMed, a health maintenance organization (HMO) in Spokane, Washington. Of these, 203 met the inclusion criteria and 164 (81%) completed our telephone survey. The main outcome measures were healthcare costs to the HMO and number of days free of migraine-related disability before and after sumatriptan treatment. Before sumatriptan treatment, 89% of patients reported severe migraine, compared with 63% after sumatriptan treatment. The number of monthly migraine disability days decreased from 6.5 days per month before sumatriptan to 3.9 days per month after sumatriptan. Healthcare utilization rates (ie, number of hospitalizations, emergency department visits) and costs were lower after the patients began taking sumatriptan. The number of different over-the-counter medicines and prescription medications (other than sumatriptan) taken for migraine disabilities decreased. Although total drug expenditures per month increased, the total migraine healthcare expenditure was 41% lower after sumatriptan was initiated. The cost-effectiveness ratio was 47% more favorable after patients started taking sumatriptan. Overall, patients reported fewer migraine-related disabilities, had lower migraine severity scores, and used fewer healthcare resources when taking sumatriptan. These changes resulted in a better cost-effectiveness ratio for migraine treatment.

Antidepressant pharmacotherapy: economic evaluation of fluoxetine, paroxetine and sertraline in a health maintenance organization.

The present study was designed to compare direct health service expenditures, for the treatment of depression, among patients enrolled in a health maintenance organization, and prescribed one of three selective serotonin reuptake inhibitors, fluoxetine, paroxetine or sertraline. Information regarding depression-related health service use was derived from the computer archive of a network-model health maintenance organization system serving 700,000 beneficiaries. A total of 744 health maintenance organization beneficiaries were found to satisfy the study selection criteria. Multivariate regression analysis was used to determine the incremental influence of selected demographic, clinical, financial and provider characteristics on health service expenditures related to the treatment of depression (ICD-9-CM, or DSM-IV code 296.2) 1 year after the start of antidepressant pharmacotherapy. Multivariate findings indicate that treatment with paroxetine increases average expenditures for physician visits ($31.93; P < or = 0.05), psychiatric visits ($19.33; NS), laboratory tests ($2.35; P < or = 0.05), hospitalizations ($85.33; P < or = 0.05), psychiatric hospitalizations ($82.01; P < or = 0.05), and antidepressant pharmacotherapy ($63.72; P < or = 0.05), for a total per capita increase in health service use of $284.68 (P < or = 0.05), compared with treatment with fluoxetine. Sertraline treatment increases average expenditures for physician visits ($21.74; P < or = 0.05), psychiatric visits ($56.79; P < or = 0.05), laboratory tests ($1.21; P < or = 0.05), hospitalizations ($70.59; P < or = 0.05), psychiatric hospitalizations ($95.75; P < or = 0.05), and antidepressant pharmacotherapy ($69.85; P < or = 0.05), for a total per capita increase in health service use of $315.96 (P < or = 0.05), compared with treatment with fluoxetine. Economic comparisons between paroxetine and sertraline did not demonstrate any significant differences in expenditures for the health services examined.

Antidepressant pharmacotherapy: economic outcomes in a health maintenance organization.

Recent pharmacotherapeutic advances in the treatment of depression have included the development of selective serotonin re-uptake inhibitors (SSRIs). The present study was designed to contrast direct health service expenditures for the treatment of depression among patients enrolled in a health maintenance organization (HMO) and prescribed either the SSRI fluoxetine or one of three tricyclic antidepressants (TCAs) (amitriptyline, nortriptyline, or desipramine). Information regarding health service utilization was derived from the computer archive of a network-model HMO system serving 400,000 beneficiaries. A total of 701 HMO beneficiaries were found to satisfy the study selection criteria. Multivariate regression analysis was used to discern the incremental influence of selected demographic, clinical, financial, and provider characteristics on 1 year post-period expenditures (PPE) for health care. Analysis-of-variance procedures with Duncan's multiple-range test, or chi-square analyses, revealed no significant difference across antidepressant pharmacotherapy for age, sex, 6-month prior-period expenditures for physician visits, psychiatric visits, laboratory tests, hospitalizations, or psychiatric hospital services related to the treatment of depression, or number of prescribed therapeutic agents for disease state processes other than depression. Receipt of fluoxetine was associated with a significantly (P < or = 0.05) higher rate of initial prescribing by psychiatrists, an increase in the number of prescriptions for antidepressant pharmacotherapy obtained (30-day supplies), and a reduction in the number of monthly intervals during which time antidepressant pharmacotherapy was not procured. Receipt of fluoxetine as antidepressant pharmacotherapy was associated with a significantly (P < or = 0.05) higher mean medication possession ratio (MPR) relative to amitriptyline, nortriptyline, or desipramine. Multivariate findings for patient-level data reflecting a definitive diagnosis of depression (n = 555) indicate that receipt of a TCA resulted in a significant (P < or = 0.05) increase in the use of physician visits ($36.07), psychiatric visits ($41.38), laboratory tests ($1.71), hospitalizations ($208.77), and psychiatric hospital services ($187.27), and a significant (P < or = 0.05) reduction in expenditures for antidepressant pharmacotherapy (-$162.21), for a total increase in health service utilization of $312.99 (P < or = 0.05) 1 year post-initiation of antidepressant pharmacotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Ipratropium bromide in the management of chronic obstructive pulmonary disease: effect on health service expenditures.

Chronic obstructive pulmonary disease (COPD), which is estimated to affect 32 million Americans, is the fifth leading cause of death in the United States. This retrospective study was designed to discern the economic utility of initial pharmacotherapy with various individual drugs in the management of COPD, as well as subsequent costs incurred as disease progression necessitated combination therapy. Data for this analysis were derived from the computer archive of a network-model health maintenance organization. During the first 6 months post-diagnosis for COPD, results indicated a significant (P < or = 0.05) increase in expenditures for physicians, hospital care, and total health service utilization for patients prescribed theophylline, a corticosteroid (triamcinolone or beclomethasone) delivered via a metered-dose inhaler, or albuterol delivered via a metered-dose inhaler as initial monotherapy compared with patients prescribed ipratropium bromide (IB) delivered via a metered-dose inhaler. Patients receiving initial pharmacotherapy with ipratropium bromide and subsequently adding albuterol used significantly less health care services (P < or = 0.05) during the first 15 months post-diagnosis for COPD than did patients prescribed all other combination therapies we evaluated.

Antioxidants can delay liver cell maturation which in turn affects gamma-glutamyltranspeptidase expression.

In normal rats just before weaning the majority of hepatocytes are mononucleated diploids, but within days the number of binucleated cells reaches a peak (approximately 50%) before declining again and there is a steady shift of diploid to tetraploid nuclei. When weanling rats were exposed to ethoxyquin (EQ), the conversion of 2N nuclei to 4N and 8N nuclei as measured by flow cytometry was slowed down. The rapid rise in the number of binucleate cells was also delayed, although the long-term effect was an increased number compared with age-matched controls. It appeared that when EQ was present in the diet, significant numbers of diploid hepatocytes undergoing DNA synthesis also underwent mitosis and cytokinesis giving rise to new diploid hepatocytes. However, many hepatocytes from animals maintained on a control diet did not undergo cytokinesis. Thus the slower 'conversion' of 2N to 4N nuclei in treated hepatocytes was due in part to promotion of cytokinesis in diploid cells undergoing DNA synthesis. The ploidy of a cell would be expected to affect gene expression. EQ is a very potent inducer of gamma-glutamyltranspeptidase (GGT), but expression depended on the age of the animals, the length of treatment time and apparently the ploidy status of the liver. In weanling rats treated with EQ for 7 days, > 80% of the hepatocytes expressed GGT, while in 42 day old rats similarly treated < 50% were positive for this enzyme. GGT expression was closely correlated with the percentage of 2N nuclei present in hepatocytes, suggesting that it was more easily induced in cells containing these nuclei than in those containing nuclei of higher ploidy. Although butylated hydroxytoluene (BHT), at the same concentration in the diet, had a similar negative effect on weight gain as did EQ, it had no effect on ploidy, nor did it induce GGT to the same extent as EQ.

The role of lymphocyte production and migration in the lymphopenia caused by 2-acetyl-4-tetrahydroxybutyl imidazole.

2-Acetyl-4-tetrahydroxybutyl imidazole (THI), a component of the food colouring ammonia caramel, has been shown to produce a profound and rapid lymphopenia in peripheral blood in the rat. In order to investigate whether the cause of the lymphopenia was due to the reduced production and influx in the circulation, redistribution of lymphocytes into other lymphoid compartments or an increased cell death, THI (1 mg/kg/day) was given in the drinking water for up to 14 days to F344 rats. A profound depletion of lymphocytes after already 1 day was only found in the blood compartment, whereas no such marked and rapid changes were found in the cellularity of other lymphoid compartments. The proportion and absolute number of DNA-synthesizing cells in each lymphoid organ was quantified using an antibody directed against incorporated 5-bromo-2'-deoxyuridine (BrdU), 1 h after a single BrdU injection. Additionally, enumeration and localization of BrdU+ cells was determined at later time points after a single BrdU injection by flow cytometry and immunocytochemistry, in order to examine the distribution and localization of recently formed (BrdU+) lymphocytes. THI treatment had no effect on the proliferation rate and the distribution of newly formed (BrdU+) cells in the lymphoid organs. However, migration studies revealed that THI treatment resulted in an increased percentage of fluorescein-labelled peripheral blood lymphocytes found in the spleen and bone marrow and a decreased percentage in the cervical and mesenteric lymph nodes, 24 h after injection. Collectively these results indicate that the lymphopenia in the peripheral blood compartment after THI treatment, is caused by a rapid sequestration of lymphocytes into the spleen and bone marrow rather than by a reduced lymphocyte production and release into the periphery. The fact that THI also caused lymphopenia in splenectomized rats, indicates that the spleen does not play an active part in the change in migrational behaviour of lymphocytes after THI treatment. Finally, as there was no increase in the absolute number of lymphocytes found in the spleen or bone marrow it seems they are rapidly degraded.

Trapping of short-lived electrophilic metabolites of pyrrolizidine alkaloids escaping from perfused rat liver.

It has been shown that a short-lived pyrrolic metabolite in fluid flowing out of isolated rat liver perfused with the pyrrolizidine alkaloid, monocrotaline, could be trapped by covalent reaction with a bed of immobilized thiol (thiol-sepharose). Larger amounts of other pyrrolic metabolites, also in the fluid, were not trapped. This provided the first direct support for the widely held hypothesis that reactive pyrrolizidine alkaloid metabolites (dehydro-alkaloids) escape from the liver to damage the lungs of rats in vivo. The relatively smaller proportion of pyrrolic metabolite from retrorsine which could be trapped in this way was consistent with the known lack of pneumotoxicity of this alkaloid. The procedure described should be suitable for trapping other types of electrophilic metabolites.

The preparation of highly enriched fractions of binucleated rat hepatocytes by centrifugal elutriation and flow cytometry.

A procedure is described for the isolation of highly enriched fractions of binucleated hepatocytes from rat liver. Liver cells isolated by EGTA and collagenase perfusion were initially subjected to centrifugal elutriation and second to flow cytometry coupled with Hoechst 33342 staining. The elutriation step yielded hepatocyte fractions which contained almost entirely mononuclear diploid cells and fractions enriched in binucleate hepatocytes. The fractions with the highest proportion of binucleated hepatocytes contained between 50 and 56% of these cells. Subsequent flow cytometric cell sorting yielded fractions which contained greater than 80% binucleated cells. These cells were viable in culture as demonstrated by the immunohistochemical detection of bromodeoxyuridine incorporation.

Sensitivity of the cell cycle to TGF beta 1 does not correlate with transformation of a rat liver epithelial cell line.

The effects of TGF beta 1 on cell cycle events in a rat liver derived epithelial cell line (BL9) and in two in vitro transformants of this line were studied by flow cytometry. Using either ethidium bromide staining or the incorporation of bromodeoxyuridine to evaluate DNA synthesis it was shown that TGF beta 1 prevented the entry of G0/G1 phase BL9 cells into S phase. TGF beta 1 did not exert its inhibitory effect(s) on DNA synthesis by the modulation of early events in the cell cycle. The tumorigenic transformed BL9 cell lines gave contrasting responses to the effects of TGF beta 1. DNA synthesis in a BL9 cell line derived by transfection with an active N-ras oncogene was unaffected by TFG beta 1 and thus appeared refractory to its growth controlling effects. On the other hand cells from a BL9 cell line derived by in vitro transformation with activated aflatoxin B1 retained their sensitivity to the effects of TGF beta 1. Thus the loss of the inhibitory effect of TGF beta 1 on DNA synthesis is not obligatory for the malignant transformation of rat liver epithelial cells.

The expression of c-myc related to the proliferation and transformation of rat liver-derived epithelial cells.

The expression of c-myc protein was studied in primary cultures of rat hepatocytes and rat liver-derived epithelial cell lines. The levels of the protein were determined by flow cytometry using a monoclonal antibody to the c-myc protein. Freshly isolated hepatocytes from normal adult male Fischer F344 rats had low but detectable levels of the protein which were similar in the different ploidies. Higher levels were detected in immortalised but untransformed rat liver cell lines, and increased expression was observed during passage through the cell cycle. Following in vitro transformation of one of the immortalised epithelial cell lines by ras genes, similar levels of c-myc expression to those present in the untransformed cells was maintained. Transformation by activated aflatoxin B1 (AFB1) resulted in lower levels of expression. The cell cycle related level of expression was also seen in the transformed cells. Similar results to those observed in the in vitro ras transfected liver-derived cell lines were obtained from in vivo AFB1-induced rat hepatoma cell lines. These results demonstrate that continuously dividing rat liver-derived cell lines have higher levels of expression of c-myc protein than non-dividing, freshly isolated hepatocytes, and that there is no further elevation in the levels observed when these cell lines are transformed. In some cases decreased levels can result from malignant transformation.

Characteristics of rat hepatocytes sorted by fluorescence-activated flow cytometry. Effects of mixed function oxidase inducers.

Fluorescence-activated flow cytometry has been used to separate rat liver parenchymal cells into five equal computer-generated regions on the basis of their mixed function activities towards diethoxyfluorescein. Enzymic activities in the sorted fractions showed 2.3-2.9-fold enrichment of 3-cyano-7-ethoxycoumarin O-deethylase, lactate dehydrogenase and pyruvate kinase activities in the cells of region 5. Cytochrome P-450 PBla and glutamine synthase activities were enriched 1.8- and 7-fold respectively in region 2 hepatocytes. Pretreatment of rats with phenobarbitone or 3-methylcholanthrene did not change the pattern of enrichment with respect to monooxygenase or lactate dehydrogenase activities. However, cytochrome P-450 PB3a and MC1a respectively were concentrated in the cells from region 5. In contrast, ethoxyquin caused enrichment of cytochrome P-450 in the hepatocytes in region 2. This fraction also contained the highest percentage of gamma-glutamyltranspeptidase positive cells.

The effect of 2-acetyl-4-tetrahydroxybutylimidazole on lymphocyte subsets in peripheral blood of the rat.

A constituent of Ammonia Caramel, 2-acetyl-4-tetrahydroxybutylimidazole (THI), is known to cause a reduction in the number of circulating lymphocytes when fed to rats. In the present study the effect of giving THI 1 mg/kg by gavage daily for 7 days on the numbers of lymphocytes in subsets has been monitored in peripheral blood. Both immunoglobulin light chain-bearing B-cells (MARK-1+) and CD5 marker-bearing T-cells (OX-19+) were reduced in number within 1 day of treatment. Within the pan-T-cell population, Class II MHC reactive helper T-lymphocytes (W3/25-) were more reduced than the Class I MHC reactive cytotoxic/suppressor T cells (OX-8+). The number of null cells (MARK-1-, OX-19-) was not affected; the majority of these cells appeared to be large granular lymphocytes.

Alterations in the cell cycle characteristics of granulosa cells during the periovulatory period: evidence of ovarian and oviductal influences.

Granulosa cells at different stages of differentiation were collected from ovarian follicles and oviducts during the periovulatory period, and their nuclear DNA content was monitored by flow cytometry to establish their cell cycle characteristics (G0 + G1, S, G2 + M). The proportion of cells in the three phases of the cell cycle varied in characteristics patterns depending upon the time they were collected, before or following ovulation. Granulosa (cumulus) cells recovered from ovulated oocytes were mitotically inactive as shown by the large proportion of cells with a 2C amount of DNA and the absence of cells in S phase. The proportion of granulosa cells in G2 + M decreased when recovery from the oviducts was delayed. In contrast, granulosa (cumulus and/or mural) cells recovered from preovulatory follicles prior to luteinizing hormone (LH) exposure contained a considerable population of cells undergoing DNA synthesis, and a decreased proportion of cells with a 2C DNA content. Our findings indicate that granulosa cells undergo dynamic and characteristics changes in all cell cycle phases during the periovulatory period, within follicular and oviductal environments. Intrafollicular events appear to play a major role in controlling DNA synthesis, proliferation, and related cell cycle events in the granulosa cells. Flow cytometric techniques provide objective and detailed information on the cell cycle characteristics of granulosa cell populations at different stages of differentiation. Elucidation of the mechanisms regulating cell cycle parameters of granulosa cells and their physiological significance thus seems feasible.

Fluorescence-activated sorting of rat hepatocytes based on their mixed function oxidase activities towards diethoxyfluorescein.

The formation of ethoxyfluorescein and fluorescein from diethoxyfluorescein by isolated rat hepatocytes has been used as a basis for separating such cells dependent on their mixed function oxidase activities by fluorescence-activated flow cytometry. Five equal fractions defined by computer-generated regions were isolated. Non-viable cells with low fluorescence (region 1) represented 10-15% of the population, while the remainder with higher mixed function oxidase activities (regions 2-5), were greater than 95% viable by Trypan Blue exclusion. In region 1, 30% of the viable cells were binucleate, 67% diploid while in region 5, 13% were binucleate and 69% tetraploid. At 3 h after sorting, following attachment to glass coverslips, exposure of cells to methyl methanesulphonate, retrorsine or norethindrone resulted in unscheduled DNA synthesis which was 2-fold higher in the tetraploid-rich region 5, while aflatoxin B1, benzo[a]pyrene or 2-acetylaminofluorene caused a 5-fold increase in unscheduled DNA synthesis in these cells, relative to the diploid-rich hepatocytes in region 2.

Specific G1-S phase cell cycle block by beryllium as demonstrated by cytofluorometric analysis.

Inhibition of cell division by beryllium (Be2+) has been examined in synchronized cultures of a liver-derived cell line (BL9L cells) using cytofluorometric cell cycle analysis. Results show that a selective dose-related block of the G1-pre-S transition is produced, with other periods of the cell cycle appearing relatively insensitive.

The ineffectiveness of reduced glutathione in preventing the development of liver tumours from aflatoxin-induced pre-neoplastic liver lesions.

Oral treatment with reduced glutathione for 10 weeks has no effect on the development of tumours from aflatoxin B1-induced gamma-glutamyl transpeptidase-positive pre-neoplastic focal lesions.