Economic evaluation of prescribing conventional and newer oral anticoagulants in older adults.

INTRODUCTION: Anticoagulants refer to a variety of agents that inhibit one or more steps in the coagulation cascade. Generally, clinical conditions that require the prescribing of an oral anticoagulant increase in frequency with age. However, a major challenge of anticoagulation use among older patients is that this group of patients also experience the highest bleeding risk. To date, economic evaluation of prescribing of anticoagulants that includes the novel or newer oral anticoagulants (NOACs) in older adults has not been conducted and is warranted. AREAS COVERED: A review of articles that evaluated the cost of prescribing conventional (e.g. vitamin K antagonists) and NOACs (e.g. direct thrombin inhibitors and direct factor Xa inhibitors) in older adults. EXPERT COMMENTARY: While the use of NOACs significantly increases the cost of the initial treatment for thromboembolic disorders, they are still considered cost-effective relative to warfarin since they offer reduced risk of intracranial haemorrhagic events. The optimum anticoagulation with warfarin can be achieved by providing specialised care; clinics managed by pharmacists have been shown to be cost-effective relative to usual care. There are suggestions that genotyping the CYP2C9 and VKORC1 genes is useful for determining a more appropriate initial dose and thereby increasing the effectiveness and safety of warfarin.

Primary care physicians' attitudes to health care reform in England.

Primary care organisation in England has been subject to particularly extensive and far-reaching reform in recent years. In 1991, a quasi-market was introduced into the National Health Service and general practitioners were offered the opportunity to manage independent budgets from which to purchase and deliver care services. Practitioners joined the scheme in increasing numbers, although it was eventually abandoned following a change of government in 1997. This paper reports the results of two surveys of primary care physicians' opinions on the English health care reforms, conducted in 1997 and 2000. It concludes that, first, those opting for discretionary budgets were significantly more supportive of the policy than those not joining the scheme and this support continued long after the scheme had been abolished. Second, professional attitudes, with respect to other terms of service in primary care, remained homogenous to a considerable degree over time. Finally, physicians in favour of imposing user charges tend to be those with responsibility for more patients, suggesting a perceived need to manage patient demand.