A comparison of asthma-related expenditures for patients started on montelukast versus fluticasone propionate as monotherapy.

BACKGROUND: The prevalence of asthma is increasing, and this chronic condition imposes a substantial economic burden worldwide. It is not known whether newer therapies, such as leukotriene receptor antagonists (LTRAs), can ease this burden. OBJECTIVE: This analysis examined the association between choice of first-line asthma control therapy and health care resource utilization and expenditures in patients with mild asthma. METHODS: A retrospective cohort analysis of claims data for patients who started therapy with fluticasone propionate or montelukast between January 1, 1997, and February 28, 1999, was performed, adjusting for baseline differences. RESULTS: Data from 343 patients (229 fluticasone; 114 montelukast) were analyzed. Patients starting therapy with fluticasone were significantly older (33.3 vs 27.6 years; P = 0.015) and significantly less likely than patients starting therapy with montelukast to have been started on control therapy by an asthma specialist (52.0% vs 69.3%; P = 0.007). There were no significant differences in mean changes in total asthma-related health care expenditures, oral steroid and antibiotic prescriptions, hospitalizations, or emergent care visits. The mean increase in total asthma-related pharmacy expenses was significantly greater for patients who were prescribed montelukast than for those prescribed fluticasone (P < 0.001). Treatment adherence was better in patients prescribed montelukast versus fluticasone (5.1 vs 3.1 prescriptions filled per year, respectively; P < 0.001). Montelukast patients had a significantly lower increase in the number of beta-agonist prescriptions filled per year than fluticasone patients (0.19 vs 0.66; P = 0.03). In the subsequent year, 4% (10/229) of fluticasone patients added or switched to an LTRA. No montelukast patients added to or switched control therapy. CONCLUSION: The mean change in total asthma-related health care expenditures was not significantly different in patients started on fluticasone propionate versus montelukast. Montelukast patients had better adherence to their treatment regimen and required fewer beta-agonist prescriptions, which is an indicator of asthma control and possibly therapeutic effectiveness.

Evaluation of a short form for measuring health-related quality of life among pediatric asthma patients.

BACKGROUND: This study was undertaken to derive and validate a short form parent-completed questionnaire to measure health-related quality of life (HRQL) in pediatric asthma patients. OBJECTIVE: The objectives of this study were to (1) use stepwise analysis to derive a shorter questionnaire from the original long-form questionnaire and (2) determine the tradeoff in precision between the long- and short-form surveys. METHODS: One hundred eighty-one pediatric asthma patients were enrolled from 4 sites. A parent of each patient completed a general and an asthma-specific questionnaire during routine office visits from June 1995 to January 1997. The questionnaire included the Child Health Questionnaire Parent Form 50, a general HRQL survey, and a 17-item asthma-specific battery assessing daytime symptoms, nighttime symptoms, and functional limitations. All scales were scored from 0 to 100, with higher scores indicating better HRQL. Analysis of variance models were used to derive short-form scales from the 17-item long-form scales, and the final asthma-specific short-form scale structure was confirmed with use of stepwise regression. Scale reliability was assessed with Cronbach's alpha. Validity of the short-form questionnaire was assessed by comparing mean scale scores according to the level of asthma severity defined by several clinical criteria. Asthma severity was assessed with use of percent predicted FEV(1), frequency and type of symptoms, parent rating of disease severity, physician rating of disease severity, and resource use (emergency department use and hospitalizations). The relative validity of each of the short-form scales was measured by comparing the proportion of variance explained by each of the short-form scales compared with the respective long-form scales. RESULTS: The 17-item asthma-specific battery was reduced to 8 items, the Integrated Therapeutics Group Child Asthma Short Form. The daytime and nighttime symptom scales for each contain 2 items and the functional limitations scale 4 items. Reliability was greater than 0.70 for each of the short-form scales. The absence of ceiling and floor effects indicates each scale's ability to detect changes at both low and high levels of functioning. Lower (poorer) mean HRQL scores for severe cases compared with mild cases, for all disease severity indicators, demonstrated clinical validity. Relative validity estimates, comparing the proportion of explained variance of the short-form scales with that of the long-form scales, ranged from 0. 85 to 1.20, indicating a similar ability to measure change. CONCLUSIONS: This study documents the development of a brief, multidimensional, 8-item questionnaire for measuring HRQL in pediatric asthma patients. The brevity of the questionnaire makes it practical for use in practice settings and to monitor patients.

Incorporating quality of life data into managed care formulary decisions: a case study with salmeterol.

Pharmacy and Therapeutics committees of managed care organizations have traditionally developed formularies by limiting the numbers and kinds of pharmaceuticals they purchase, with the goal of cutting costs. These attempts to manage pharmaceutical costs do not take into account the interrelationship of the costs of various components of care; thus, drug costs may decrease, but expenditures for utilization of other resources may increase. Cost-minimization and basic cost-effectiveness studies, on which many prior- authorization and formulary programs are based, only evaluate only the cost of the drug and its effectiveness. However, with the heightened competition in the healthcare market, emphasis is increasingly being laid on patient satisfaction and outcomes. Cost-utility analysis is a potentially superior pharmacoeconomic tool because it evaluate the effect of drug therapy on quality of life; however, data from such analyses are seldom readily available to the committees that evaluate a drug's potential effects on the entire healthcare system. The purpose of this review is to stress the importance of approaching formulary management from a wider perspective and to emphasize that the results of cost-utility studies should be proactively evaluated and incorporated into decisions regarding formularies. This is especially important for symptom-intensive diseases, such as asthma, in which the quality of life can be notably impaired. Cost-utility analyses should be conducted for all newer therapies, such as salmeterol, which are highly effective and which have a positive impact on quality of life, to determine the overall effect on the managed care plan's budget.

Tilarin in combination with astemizole.

This multicentre double-blind, placebo controlled study had a practical objective, based on the expectation that many patients with seasonal allergic rhinitis will be prescribed oral antihistamine monotherapy by their primary care physician, whereas allergy specialists are more likely to prescribe combination therapy including antiinflammatories. The specific question was, "Will the addition of nedocromil sodium 1% nasal spray to astemizole tablets improve control of symptoms of seasonal allergic rhinitis induced by ragweed pollen, as compared to astemizole therapy alone?'. Following a one-week baseline, planned to coincide with the start of the local ragweed pollen season, patients (aged 12-64) were randomly assigned to four weeks' double-blind test treatment with either nedocromil sodium 1% nasal spray four times daily (QID) + astemizole (n = 146) or placebo nasal spray + astemizole (n = 148) or double-dummy (nasal spray + capsules) placebo (n = 71). Patient diary cards were kept throughout the five weeks, and clinic visits were made before and after baseline and after one and four weeks' treatment. During the 10-day peak pollen period, the diary card rhinitis symptom summary score (0-4 severity scale) was significantly reduced in patients receiving either astemizole alone (p < 0.001) or the combination therapy (p < 0.001) as compared with placebo. Direct comparison of the active treatments further showed that symptoms were significantly less severe (p < 0.01) with the combined therapy than with astemizole alone, and this despite significantly greater reliance on permitted rescue medications (p < 0.05 for pseudoephedrine usage) in the astemizole group. Clinical assessments of rhinitis made during the peak pollen visit, after the first week of test treatment, were also significantly (p < 0.05 - p < 0.01) in favour of combined therapy with nedocromil sodium 1% nasal spray + astemizole rather than astemizole alone, and at the same time this preference was confirmed by physician (p = 0.011) and patient (p = 0.003) opinions of symptom control. In conclusion, this antiinflammatory + antihistamine treatment proved superior to antihistamine alone for effective management of allergic rhinitis. The combined therapy worked quickly and was well-tolerated, with no serious adverse events or untoward effects on blood or urine variables.

The utility of outcomes information at the point of service.

A systemwide outcomes management plan is in the process of implementation at Dean Medical Center. Plans for data collection include a core data set of patient satisfaction, basic health, and functional and risk status along with specific clinical and clinically related functional status reported by patients and providers.

Parapneumonic empyema in children: diagnosis and management.

Parapneumonic effusion can be a significant problem if it is not recognized and treated promptly. The amount of pleural fluid at presentation is usually small and may not be detected on physical examination. If pleural fluid is seen on radiographs, thoracentesis must be performed. Early, free-flowing parapneumonic effusions usually respond clinically to antibiotic therapy without the necessity of draining the pleural space. Distinguishing between exudative effusion and empyema is crucial. Failure of effusion or empyema to respond to the treatment is usually due to failure to adequately drain the pleural space or inappropriate antibiotic therapy. If chest tube drainage does not result in a lower temperature and an appropriate clinical response within a few days, further evaluation by computed tomographic scanning and surgical consultation are indicated. In patients with pleural effusion and empyema that responds poorly to medical and/or surgical therapy, underlying causes or associated debilitating disease should be excluded.