RESUMO
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naïve patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use.
Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Cuidados Pós-Operatórios/normas , Analgésicos Opioides/efeitos adversos , Consenso , Esquema de Medicação , Humanos , Incidência , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/epidemiologia , Medição de Risco , Fatores de Risco , Terminologia como Assunto , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Recent changes in national reimbursement policies expand the ability of pharmacists to seek reimbursement for cognitive services. The quality of pharmacist-provided cognitive services has, until now, remained unassessed. Pharmacists should demonstrate the quality and value of their work to ensure the continued and expanded acceptance of reimbursement for their services. A preliminary step in assessing quality is to compare agreement between pharmacists for basic problem identification. OBJECTIVE: To quantify agreement between pharmacist reviewers for problem identification among Utah Medicaid recipients. METHODS: Five pharmacists retrospectively reviewed drug regimens, patient characteristics, diagnosis codes, and procedures for 80 Medicaid patients in September 2008 and identified drug-related problems (DRPs) in 15 predetermined categories. Data for each patient were reviewed twice, and each combination of 2 pharmacists reviewed the same 8 patients' information. We calculated a reliability coefficient to compare the number of DRPs identified and used prevalence and bias adjusted kappa (PABAK) to determine interrater reliability for the presence of a specific DRP. RESULTS: Of the 15 DRPs categorized by pharmacist reviewers, 1 (untreated indications) had a PABAK coefficient of 0.20, indicating a relatively low level of agreement between reviewers. All other DRP categories had good to excellent agreement, with PABAK coefficients ranging between 0.43 and 0.98. CONCLUSIONS: Pharmacist reviewers exhibited less variability in DRP identification or categorization than had been expected for most categories. This work supports the conclusion that pharmacists in our center provide a basic and necessary level of quality for problem assessment. Future work is needed to document the impact of this quality on patient outcomes.
Assuntos
Seguro de Serviços Farmacêuticos/economia , Assistência Farmacêutica/economia , Farmacêuticos/economia , Mecanismo de Reembolso , Adulto , Revisão de Uso de Medicamentos/métodos , Feminino , Humanos , Reembolso de Seguro de Saúde/economia , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Papel Profissional , Qualidade da Assistência à Saúde , Estados Unidos , UtahRESUMO
BACKGROUND: Reliance on prescription opioids to manage pain has been associated with increases in diversion, overdose, and addiction. Prevalence of misuse and abuse has been shown to be higher among government-insured populations than commercially insured populations. However, the prevalence and costs of misuse/abuse among the Medicare fee-for-service (FFS) population has not been studied. OBJECTIVES: To (a) determine the prevalence and costs of prescription opioid misuse/abuse and (b) evaluate the prevalence and costs associated with those identified as at risk for opioid misuse/abuse in Medicare FFS beneficiaries. METHODS: This retrospective case-control study used Medicare claims data for the calendar years of 2010 and 2011 and included Medicare beneficiaries aged at least 18 years. The index date was the date of first diagnosed misuse/abuse or at risk for abuse and had to occur between July 1, 2010, and June 30, 2011, and beneficiaries had to have at least 6 months continuous eligibility before and after the index date. Matching (1:1) was used for comparing opioid misusers/abusers with nonabuser controls, as well as comparing patients at risk for opioid abuse with controls not at risk for abuse. Controls were matched to cases by gender, age, disability, and geographic region. The index date of the control patient was set equal to the index date of the matched case. RESULTS: Prevalence of misuse/abuse in the Medicare FFS population was 13.1 per 1,000 persons, with the majority among patients receiving Medicare based on disability (76.2%). The prevalence of at risk for misuse/abuse was 117.4 per 1,000 persons. Approximately half of the Medicare FFS patients used an opioid. Overall total annual unadjusted mean costs of health care resources were significantly greater for abusers than for matched controls ($46,194 vs. $21,964; P < 0.0001), with a mean annual excess cost of $24,230. The overall total adjusted 6-month post-index mean costs of health care resources for abusers was significantly greater than that of matched controls ($33,942 vs. $10,754; P < 0.0001), with a mean excess cost of $23,188. CONCLUSIONS: The prevalence of diagnosed abuse among Medicare FFS population (13.1 per 1,000 persons) was higher than other payer groups studied using similar ICD-9-CM codes, and the majority of abuse was among those receiving Medicare based on disability (76.2%). The prevalence of at-risk abuse was 9 times higher than the prevalence of diagnosed abuse. As with other studies, health care resource utilization and costs were significantly greater for diagnosed abuse than matched controls. DISCLOSURES: This study was sponsored by Pfizer. Roland is a Pfizer employee and stockholder and was involved in all aspects of the study as part of a mid-career fellowship in pharmacoeconomics with the University of Utah. Ye and Stevens are employees of University of Utah, and Oderda was an employee of University of Utah, which received financial support from Pfizer in connection with the development of this manuscript. Oderda also reports consulting fees from Pfizer, Trevena, and Pacira, unrelated to this study. The results of this study were presented at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; Orlando, FL, and the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA.
Assuntos
Analgésicos Opioides/efeitos adversos , Overdose de Drogas/epidemiologia , Medicare/economia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Uso Indevido de Medicamentos sob Prescrição/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/economia , Estudos de Casos e Controles , Overdose de Drogas/economia , Overdose de Drogas/etiologia , Planos de Pagamento por Serviço Prestado/economia , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/etiologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prevalência , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
Opioid-induced respiratory depression (OIRD) and postoperative nausea and vomiting (PONV) are challenging, resource-intensive, and costly opioid-related adverse events (ORAEs). Utilizing the Premier Healthcare Database, we identified patients > 18 years old, who underwent at least one surgical procedure of interest (i.e., cardiothoracic/vascular, general/colorectal, obstetric/gynecologic, orthopedic, or urologic), and received at least one dose of intravenous morphine, hydromorphone, or fentanyl for acute postoperative pain. The incidence of OIRD and PONV using ICD-9 codes, factors influencing these AEs, length of stay (LOS) and related costs were analyzed. Among 592,127 inpatient stays, rates of respiratory depression ranged from 3% (obstetric/gynecologic) to 17% (cardiothoracic/vascular) and nausea/vomiting from 44% (obstetric/gynecologic) to 72% (general/colorectal). Increased odds of OIRD were associated with older age (cardiothoracic/vascular, general/colorectal, obstetric/gynecologic); obesity, respiratory conditions, and sleep apnea (all surgery groups); opioid dose (cardiothoracic/vascular, general/colorectal, orthopedic); and sedative use after day 1. Increased odds of PONV were associated with younger age, female sex, and major disease severity. When respiratory depression or nausea/vomiting was present versus absent, LOS was significantly longer, and hospital costs were higher. In this analysis, OIRD and PONV were more prevalent than previously reported, were associated with identifiable risk factors, and had substantial effects on resource utilization and costs.
Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/induzido quimicamente , Insuficiência Respiratória/induzido quimicamente , Adulto , Idoso , Analgésicos Opioides/administração & dosagem , Estudos de Coortes , Feminino , Fentanila/administração & dosagem , Humanos , Hidromorfona/efeitos adversos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Estudos Retrospectivos , Fatores de RiscoRESUMO
Rheumatoid arthritis (RA) management requires monitoring of disease activity to determine course of treatment. Global assessments are used in clinical practice to determine RA disease activity. Monitoring disease activity via biomarkers may also help providers optimize biologic and nonbiologic drug use while decreasing overall drug spend by delaying use of expensive biologic therapies. By testing multiple biologic domains at the same time, a multibiomarker disease activity test may have utility in RA patient management, through improved intra- and inter-rater reliability. This report provides a comprehensive review of studies of objective measures, single biomarkers and multibiomarker disease activity tests as disease activity measures to decrease uncertainty in treatment decisions, and of biomarkers' potential impact on economic and clinical outcomes of treatment choices.
Assuntos
Artrite Reumatoide/tratamento farmacológico , Biomarcadores/metabolismo , Medicina de Precisão/economia , Artrite Reumatoide/metabolismo , Tomada de Decisão Clínica , Análise Custo-Benefício , Gerenciamento Clínico , Progressão da Doença , Humanos , Terapia de Alvo Molecular , Reprodutibilidade dos Testes , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Opioid analgesics remain a mainstay in the treatment of pain associated with surgical procedures. Such use is associated with adverse drug events (ADEs). OBJECTIVE: To investigate the impact of opioid-related ADEs on total hospital costs and length of stay (LOS) in adult surgical patients. METHODS: This was a retrospective matched cohort study using data from computerized medical records. ADE cases were prospectively detected using computerized surveillance and verified by pharmacists. Surgical patients treated at LDS Hospital in Salt Lake City from January 1, 1998, to December 31, 2003, were included. The primary outcomes were costs and hospital LOS associated with opioid-related ADEs and the relationship of opioid dose to ADE events. RESULTS: Patients experiencing opioid-related ADEs had significantly increased median total hospital costs (7.4% increase; 95% CI 3.83 to 10.96; p < 0.001) and increased median LOS (10.3% increase; 95% CI 6.5 to 14.2; p < 0.001) compared with matched non-ADE controls. The increased costs attributable to ADEs, by surgery type, were general surgery ($676.51; 95% CI 351.50 to 1001.50), orthopedics ($861.50; 95% CI 448.20 to 1274.80), and obstetrics/gynecology ($540.90; 95% CI 281.40 to 800.40). Similarly, increased LOS attributable to ADEs, by surgery type, were general surgery (0.64 days; 95% CI 0.40 to 0.88), orthopedics (0.52 days; 95% CI 0.33 to 0.71), and obstetrics/gynecology (0.53 days; 95% CI 0.33 to 0.72). Higher doses of opioids were associated with increased risk of experiencing ADEs (OR 1.3; 95% CI 1.07 to 1.60; p = 0.01). CONCLUSIONS: Opioid-related ADEs following surgery were associated with significantly increased LOS and hospitalization costs. These ADEs occurred more frequently in patients receiving higher doses of opioids.
Assuntos
Analgésicos Opioides/efeitos adversos , Custos Hospitalares/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Adulto , Sistemas de Notificação de Reações Adversas a Medicamentos , Idoso , Estudos de Coortes , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To estimate healthcare resource utilization, associated costs, and number needed to harm (NNH) from a physician's decision to prescribe extended-release (ER) non-abuse-deterrent opioids (non-ADO) as compared to ER ADOs in a chronic pain population. DESIGN: A 12-month probabilistic simulation model was developed to estimate the reduction of misuse and/or abuse from a physician's prescribing decisions for 10,000 patients. Model inputs included probabilities for opioid misuse and/or abuse-related events, opioid discontinuation, and switching from ADO to non-ADO. Estimated reductions in abuse associated with ADOs were obtained from positive subjective measures using human abuse liability studies. The model was run separately for commercial, Medicare, Medicaid, and Veterans Administration (VA) populations. The difference in healthcare resource utilization and associated costs (2015 USD) between the ADO and non-ADO simulations was calculated. NNH for non-ADO was also calculated. RESULTS: Misuse and/or abuse-related events for patients prescribed ER non-ADOs ranged from 223-1,410 and associated costs ranged from $20-$98 per patient for commercial and Medicare populations, respectively. Prescribing ER ADOs were associated with 87, 289, 264, and 417 fewer misuse and/or abuse-related events, saving $8, $35, $21, and $29 per patient in commercial, VA, Medicaid, and Medicare populations, respectively. NNH ranged from 185 in the commercial population to 40 in the Medicare population. Results were sensitive to decreases in the probability of misuse and/or abuse events but showed reductions. CONCLUSIONS: A physician's decision to prescribe ER ADOs could lead to large reductions in misuse and/or abuse-related events and associated costs across many patient populations.
Assuntos
Formulações de Dissuasão de Abuso/economia , Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Crônica/economia , Custos de Medicamentos , Padrões de Prática Médica/economia , Formulações de Dissuasão de Abuso/efeitos adversos , Analgésicos Opioides/efeitos adversos , Dor Crônica/diagnóstico , Simulação por Computador , Redução de Custos , Análise Custo-Benefício , Preparações de Ação Retardada , Composição de Medicamentos , Prescrições de Medicamentos/economia , Substituição de Medicamentos/economia , Humanos , Cadeias de Markov , Medicaid/economia , Medicare/economia , Modelos Econômicos , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Uso Indevido de Medicamentos sob Prescrição/economia , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Transtornos Relacionados ao Uso de Substâncias/economia , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Estados Unidos , United States Department of Veterans Affairs/economiaRESUMO
STUDY OBJECTIVES: To determine the incidence of heparin-induced thrombocytopenia (HIT) in patients admitted to a medical service who were given unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) to prevent venous thromboembolism, the incremental cost of developing HIT, and the cost consequences of using LMWH to prevent venous thromboembolism in medical patients. DESIGN: Retrospective analysis with a nested case-control. SETTING: University-affiliated tertiary-care hospital. PATIENTS: A total of 10,121 adult medical patients admitted between August 1, 2000, and November 2, 2004, received UFH or LMWH to prevent venous thromboembolism during their admission. From these, patients with immune-mediated HIT were identified and served as case patients, and 3-5 matched control patients were identified for each case patient. MEASUREMENTS AND MAIN RESULTS: The development of HIT was determined for patients who received LMWH and for patients who received UFH. Costs were compared between the patients with HIT and the matched control patients. The cost of using LMWH to prevent venous thromboembolism was compared with the cost of using UFH. In patients receiving UFH and those receiving LMWH, the incidence of HIT was 0.51% (43/8420) and 0.084% (1/1189), respectively (p=0.037), with an overall incidence of 0.43% (44/10,121). Admissions that included development of HIT incurred an average cost of 56,364 dollars compared with 15,231 dollars (p<0.001) for admissions without HIT. Using LMWH to prevent venous thromboembolism in medical patients cost 13.88 dollars less per patient than using UFH. CONCLUSIONS: For the prophylaxis of venous thromboembolism, LMWH was associated with a lower incidence of HIT than UFH in medical patients. An admission during which the patient develops HIT costs significantly more than an admission during which the patient does not develop HIT. Low-molecular-weight heparin is cost-effective for prevention of venous thromboembolism in medical patients.
Assuntos
Anticoagulantes/efeitos adversos , Heparina/efeitos adversos , Trombocitopenia/economia , Tromboembolia/prevenção & controle , Trombose Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Estudos de Casos e Controles , Quimioprevenção , Feminino , Heparina/análogos & derivados , Heparina/uso terapêutico , Hospitais Universitários , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombocitopenia/induzido quimicamente , Trombocitopenia/epidemiologia , Utah/epidemiologiaRESUMO
BACKGROUND: Despite numerous reports of state Medicaid drug utilization review (DUR) programs, little data are available about the prevalence of drugrelated problems (DRPs) in Medicaid patients. A university-based, pharmacist-run DUR program for high utilizers was created as an alternative to imposition of a statutory limit of 7 medications per month in the Utah Medicaid program in 2002. The DUR program was designed to suggest ways that high-utilizing patients could decrease their total number of medications to 7 or fewer prior to imposition of the 7-medication limit at some time in the future. OBJECTIVE: To describe the experience in 1 Medicaid DUR program and to report the prevalence of DRPs and cost-saving opportunities (CSOs) among a population of Medicaid recipients who were high utilizers of prescription drugs. METHODS: DRPs were identified by 5 clinical pharmacists employed by the Drug Regimen Review Center (DRRC) in Salt Lake City. The purpose of the center was to provide drug therapy review services for a select number of Utah Medicaid recipients (200-300 per month) who exceeded a 7-medication limit during the calendar years 2003 and 2004. RESULTS: Out of 391,890 eligible Medicaid recipients, 242,411 (62%) received at least 1 medication, and 16,958 (4.3%) exceeded the 7-medication limit during the review period. Of those exceeding the limit, the DRRC reviewed a total of 3,706 (21.9%) patients, representing the highest utilizers by volume of medication. The prevalence of DRPs considered clinically important in the review cohort was 79.7% of patients, including therapeutic duplications in 54.6% of patients, dose form optimization in 29.7%, and inappropriate uncoordinated care in 25.3%. The average pharmacy cost per month for patients with at least 1 DRP was 1,081 dollars; by contrast, the average pharmacy cost per month for all other patients receiving at least 1 prescription was 91 dollars. CONCLUSIONS: Approximately 4% of Medicaid recipients exceeded the 7-medication monthly limit. Among the 22% highest utilizers in this group, 48% of nursing home residents and 87% of ambulatory recipients had at least 1 DRP, or an overall rate of 80% of high-use Medicaid recipients or as much as 3.2% of the Medicaid population.
Assuntos
Redução de Custos , Revisão de Uso de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Medicaid , Polimedicação , Idoso , Idoso de 80 Anos ou mais , Redução de Custos/estatística & dados numéricos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Farmacêutica , UtahRESUMO
This study assessed the "real-world" risk of serious gastrointestinal (GI) toxicities, defined as perforations, ulcers and bleeds (PUBs) in a U.S. representative population that was using two commonly available over-the-counter (OTC) non-selective nonsteroidal antiinflammatory drugs (NSAIDs), naproxen or ibuprofen with or without concomitant aspirin usage. A retrospective review of a commercially available electronic medical record (EMR) database containing the ambulatory health record data for over 3.2 million individuals was conducted. Subjects were eligible for inclusion in the study if they received an OTC dosage of naproxen (220 mg) or ibuprofen (200 mg). An index date for each subject was defined as the first mention of an OTC NSAID in the medication list of the EMR dataset. Subjects were excluded from the analysis if they met any criteria, which can lead to GI bleeding complications. The dataset was analyzed for PUBs, as indicated by the ICD-9 diagnosis codes for gastric, duodenal, peptic, or gastrojejunal ulcers, or GI hemorrhage, as well as the concomitant use of aspirin. A pre/post-analysis was conducted using a case-crossover design with subjects as their own controls. The index date was the defining event, in order to determine the odds ratio associated with OTC NSAID usage. A pre-index time period of 365 days was used for prior PUBs. For the post-index time period, only PUBs that occurred within 90 days of the OTC NSAID index date were considered. The data set contained 11,957 subjects on naproxen and 38,507 subjects on ibuprofen. In both cases, OTC NSAID usage was associated with a statistically significant increase in the odds ratio for PUBs. Subjects on ibuprofen had an odds ratio of 1.38 (95% CI 1.07-1.78, P=0.01). Naproxen subjects exhibited an odds of 1.54 (95% CI 1.04-2.28, P=0.03). The concomitant aspirin population consisted of 2,328 naproxen subjects and 4,843 ibuprofen subjects. Concomitant aspirin usage was also associated with a significantly higher risk for PUBs than the corresponding monotherapy. Subjects taking both ibuprofen and aspirin had an odds ratio of 3.36 (2.36-4.80, P<.00001), while those on naproxen and aspirin had an odds ratio of 2.07 (1.23-3.49, P=.005) relative to those subjects on ibuprofen and naproxen monotherapy, respectively. Utilizing a national electronic medical record database representing patients seen predominantly in a primary care setting, this study has documented the "real-world" risk associated with the use of two common OTC NSAIDs, as well as the increased risk associated with concomitant aspirin use in this population.
Assuntos
Anti-Inflamatórios não Esteroides/efeitos adversos , Gastroenteropatias/induzido quimicamente , Ibuprofeno/efeitos adversos , Naproxeno/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/administração & dosagem , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Criança , Pré-Escolar , Quimioterapia Combinada , Feminino , Humanos , Ibuprofeno/administração & dosagem , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Naproxeno/administração & dosagem , Razão de Chances , Estudos RetrospectivosRESUMO
This paper describes how investigators may design, conduct, and report economic evaluations of pharmacotherapy for pain and symptom management. Because economic evaluation of therapeutic interventions is becoming increasingly important, there is a need for guidance on how economic evaluations can be optimally conducted. The steps required to conduct an economic evaluation are described to provide this guidance. Economic evaluations require two or more therapeutic interventions to be compared in relation to costs and effects. There are five types of economic evaluations, based on analysis of: (1) cost-effectiveness, (2) cost-utility, (3) cost-minimization, (4) cost-consequence, and (5) cost-benefit analyses. The six required steps are: identify the perspective of the study; identify the alternatives that will be compared; identify the relevant costs and effects; determine how to collect the cost and effect data; determine how to perform calculation for cost and effects data; and determine the manner in which to depict the results and draw comparisons.
Assuntos
Dor/tratamento farmacológico , Dor/economia , Projetos de Pesquisa , Custos e Análise de Custo , Farmacoeconomia , Qualidade de Vida , Reprodutibilidade dos TestesRESUMO
Data from the U.S. Centers for Medicare and Medicaid Services' Medicaid database were analyzed to define recent trends in the use and cost of opioid medications United States as a whole and in seven states between 1998 and 2003. Over this time period, total Medicaid prescriptions for opioids have nearly doubled and, in nominal terms, expenditures have nearly tripled. The morphine derivatives account for the largest share of these increases. By 2003, opioids represented about a four percent share of all Medicaid prescription drugs. Variations among the states in per-enrollee spending on opioids are substantial. The appropriateness of these variations is unknown.
Assuntos
Analgésicos Opioides/economia , Custos de Medicamentos/tendências , Medicaid/economia , Medicaid/tendências , Uso de Medicamentos , Humanos , Pacientes Ambulatoriais , Estudos Retrospectivos , Estados UnidosRESUMO
We conducted a systematic review to evaluate worldwide human English published literature from 2009 to 2014 on prevalence of opioid misuse/abuse in retrospective databases where International Classification of Diseases (ICD) codes were used. Inclusion criteria for the studies were use of a retrospective database, measured abuse, dependence, and/or poisoning using ICD codes, stated prevalence or it could be derived, and documented time frame. A meta-analysis was not performed. A qualitative narrative synthesis was used, and 16 studies were included for data abstraction. ICD code use varies; 10 studies used ICD codes that encompassed all three terms: abuse, dependence, or poisoning. Eight studies limited determination of misuse/abuse to an opioid user population. Abuse prevalence among opioid users in commercial databases using all three terms of ICD codes varied depending on the opioid; 21 per 1000 persons (reformulated extended-release oxymorphone; 2011-2012) to 113 per 1000 persons (immediate-release opioids; 2010-2011). Abuse prevalence in general populations using all three ICD code terms ranged from 1.15 per 1000 persons (commercial; 6 months 2010) to 8.7 per 1000 persons (Medicaid; 2002-2003). Prevalence increased over time. When similar ICD codes are used, the highest prevalence is in US government-insured populations. Limiting population to continuous opioid users increases prevalence. Prevalence varies depending on ICD codes used, population, time frame, and years studied. Researchers using ICD codes to determine opioid abuse prevalence need to be aware of cautions and limitations.
Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Analgésicos Opioides/efeitos adversos , Bases de Dados Factuais , Humanos , Classificação Internacional de Doenças , PrevalênciaRESUMO
Painful diabetic neuropathy (PDN) affects nearly half of patients with diabetes. The objective of this study was to compare the cost-effectiveness of starting patients with PDN on pregabalin (PRE), duloxetine (DUL), gabapentin (GABA), or desipramine (DES) over a 10-year time horizon from the perspective of third-party payers in the United States. A Markov model was used to compare the costs (2013 $US) and effectiveness (quality-adjusted life-years [QALYs]) of first-line PDN treatments in 10,000 patients using microsimulation. Costs and QALYs were discounted at 3% annually. Probabilities and utilities were derived from the published literature. Costs were average wholesale price for drugs and national estimates for office visits and hospitalizations. One-way and probabilistic (PSA) sensitivity analyses were used to examine parameter uncertainty. Starting with PRE was dominated by DUL as DUL cost less and was more effective. Starting with GABA was extendedly dominated by a combination of DES and DUL. DES and DUL cost $23,468 and $25,979, while yielding 3.05 and 3.16 QALYs, respectively. The incremental cost-effectiveness ratio for DUL compared with DES was $22,867/QALY gained. One-way sensitivity analysis showed that the model was most sensitive to the adherence threshold and utility for mild pain. PSA showed that, at a willingness-to-pay (WTP) of $50,000/QALY, DUL was the most cost-effective option in 56.3% of the simulations, DES in 29.2%, GABA in 14.4%, and PRE in 0.1%. Starting with DUL is the most cost-effective option for PDN when WTP is greater than $22,867/QALY. Decision makers may consider starting with DUL for PDN patients.
Assuntos
Aminas/uso terapêutico , Analgésicos/uso terapêutico , Ácidos Cicloexanocarboxílicos/uso terapêutico , Desipramina/uso terapêutico , Neuropatias Diabéticas/tratamento farmacológico , Cloridrato de Duloxetina/uso terapêutico , Pregabalina/uso terapêutico , Ácido gama-Aminobutírico/uso terapêutico , Aminas/economia , Analgésicos/economia , Análise Custo-Benefício , Ácidos Cicloexanocarboxílicos/economia , Desipramina/economia , Neuropatias Diabéticas/economia , Cloridrato de Duloxetina/economia , Gabapentina , Custos de Cuidados de Saúde , Humanos , Modelos Econômicos , Pregabalina/economia , Anos de Vida Ajustados por Qualidade de Vida , Ácido gama-Aminobutírico/economiaRESUMO
OBJECTIVE: Providing care to patients with comorbid medical problems may result in complicated, multiple drug therapy regimens, increasing the risk of clinically meaningful drug-drug interactions (DDIs). The purpose of this article is to describe the prevalence of DDIs and provide examples on how to identify and intervene on DDIs. METHODS: We described DDI data from the Utah Drug Regimen Review Center, where adult Medicaid patients were reviewed by pharmacists from 2005 to 2009. Patients were selected by the number of prescriptions filled per month (>7) or having a high RxRisk score. SUMMARY: A total of 8860 patients were reviewed, and 16.6% had at least 1 clinically meaningful DDI. Patients with DDIs were slightly younger (mean age 45.2 vs 48.2), more likely to be female (75.0% vs 68.9%), and had more prescriptions per month (13.4 vs 12.5) compared to patients without (P < .001). Pharmacodynamic DDIs were more prevalent (80.2%) than pharmacokinetic. Pharmacodynamic DDIs mainly occurred with drugs used to treat psychiatric/seizure/sleep disorders (69.4%) and pain/migraine (56.6%). Pharmacokinetic DDIs mainly occurred with drugs used to treat psychiatric/seizure/sleep disorders (53.2%), cardiovascular diseases (46.3%), and infectious diseases (29.6%). CONCLUSIONS: Clinically meaningful DDIs are common in patients with complex medication regimens. A systematic approach for identifying DDIs, determining clinical significance, formulating patient-specific recommendations, and communicating recommendations is important in pharmacy practice.
Assuntos
Serviços Comunitários de Farmácia , Interações Medicamentosas , Fatores Etários , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polimedicação , Prevalência , Fatores SexuaisRESUMO
This study compared patient characteristics and health care costs between newly treated diabetic painful neuropathy (DPN) patients receiving mono- pharmacotherapy and those receiving combination pharmacotherapy. A retrospective cohort was developed through Inovalon's Medical Outcomes Research for Effectiveness and Economics Registry (MORE2) database. Patients included were ≥18 years on the date of first DPN prescription: tricyclic antidepressant, opioids, duloxetine, gabapentin, pregabalin, or lidocaine. The authors conducted a simple proportional hazards model comparing times to discontinuation, switch, or addon. Multiple logistic regression was used to identify predictors of combination pharmacotherapy. There were 7145 patients on mono-pharmacotherapy and 421 patients on combination pharmacotherapy. Patients receiving combination pharmacotherapy were 130% more likely to discontinue their medications than patients receiving mono-pharmacotherapy. Female patients and those with > 7 comorbidities were more likely to be started with combination pharmacotherapy. Elderly patients were less likely to be started with combination pharmacotherapy. The total cost of care difference between mono- and combination pharmacotherapy was not statistically significant (P = .66); therefore, newly treated DPN patients should add on another medication sooner than 30 days when considering combination pharmacotherapy. All first-line medications have similar efficacy; for this reason, cost should be considered in the treatment decision.
Assuntos
Analgésicos/administração & dosagem , Adolescente , Adulto , Fatores Etários , Idoso , Analgésicos/economia , Analgésicos/uso terapêutico , Estudos de Coortes , Comorbidade , Neuropatias Diabéticas/tratamento farmacológico , Neuropatias Diabéticas/economia , Quimioterapia Combinada , Feminino , Custos de Cuidados de Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: The objective of this study was to examine the relationship of work loss associated with gastro- the relationship of work loss associated with gastro- the relationship of work loss associated with gastro-esophageal reflux disease (GERD) and peptic ulcer disease (GERD) and peptic ulcer disease (PUD) in a large population of employed individuals in the United States (US) and quantify the individuals in the United States (US) and quantify the economic impact of these diseases to the employer. METHODS: A proprietary database that contained work place absence, disability and workers' compensation data in addition to prescription drug and medical claims was used to answer the objectives. Employees with a medical claim with an ICD-9 code for GERD or PUD were identified from 1 January 1997 to 31 December 2000. A cohort of controls was identified for the same time period using the method of frequency matching on age, gender, industry type, occupational status, and employment status. Work absence rates and health care costs were compared between the groups after adjusting for demo graphic, and employment differences using analysis of covariance models. RESULTS: There were significantly lower (p < 0.05) prescription, and outpatient costs in the controls compared to the disease groups, although the eta-square values were very low. The mean work absence attributed to sick days was 2.8 (+/- 2.3) for controls, 3.4 (+/- 2.5) for GERD, 3.2 (+/- 2.6) for PUD, and 3.2 (+/- 2.3) days for GERD + PUD. For work loss, a significantly higher (p < 0.05) rate of adjusted all-cause absenteeism and sickness-related absenteeism were observed between the disease groups versus the controls. In particular, controls had an average of 1.2 to 1.6 days and 0.4 to 0.6 lower all-cause and sickness-related absenteeism compared to the disease groups. The incremental economic impact projected to a hypothetical employed population was estimated to be $3441 for GERD, $1374 for PUD, and $4803 for GERD + PUD per employee per year compared to employees without these diseases. CONCLUSIONS: Direct medical cost and work absence in employees with GERD, PUD and GERD + PUD represent a significant burden to employees and employers.
Assuntos
Refluxo Gastroesofágico/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Úlcera Péptica/economia , Indenização aos Trabalhadores/economia , Indenização aos Trabalhadores/estatística & dados numéricos , Absenteísmo , Adulto , Estudos de Casos e Controles , Bases de Dados Factuais , Feminino , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Ocupações , Úlcera Péptica/complicações , Úlcera Péptica/terapia , Estudos Retrospectivos , Estados Unidos , Local de TrabalhoRESUMO
Many underserved patients in Utah lack insurance coverage for health care and prescription drugs but are provided medical care in community health centers (CHCs). Before June 2000, comprehensive pharmacy services were not provided to these patients at a Utah CHC. As part of a Health Resources and Services Administration grant, a collaborative agreement between the University of Utah College of Pharmacy and Utah CHCs was established so that a faculty clinician who is a certified diabetes educator (CDE) could provide diabetes education and care to underserved patients. The College of Pharmacy faculty clinician (pharmacist CDE) collaborated with physicians and midlevel practitioners to provide diabetes education and care for 176 patients. In addition to initial diabetes education, the pharmacist CDE provided continuing disease management by providing information and feedback to patients and recommendations to providers. The pharmacist CDE conducted continuing chart reviews to track certain parameters, such as laboratory test results for hemoglobin A 1c (A1C) and lipid levels, and blood pressure. Patients were followed for 1-3 years. The same outcome data were also collected for 176 patients with diabetes mellitus in another CHC clinic to provide a comparison group. Total cholesterol, low-density lipoprotein cholesterol, A1C, and triglyceride levels declined significantly from baseline at both sites. However, more patients who were provided care by the pharmacist CDE reached the American Diabetes Association A1C target goal of below 7%.
Assuntos
Centros Comunitários de Saúde/organização & administração , Comportamento Cooperativo , Atenção à Saúde/métodos , Diabetes Mellitus/diagnóstico , Área Carente de Assistência Médica , Educação de Pacientes como Assunto/métodos , Pessoal Técnico de Saúde/estatística & dados numéricos , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/fisiopatologia , Tratamento Farmacológico/métodos , Estudos de Avaliação como Assunto , Feminino , Seguimentos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto/normas , Educação de Pacientes como Assunto/tendências , Resultado do Tratamento , Utah/epidemiologiaRESUMO
Cost utility analysis is a form of cost-effectiveness analysis in which outcomes are adjusted for quality and quantity of life. This type of analysis is used widely in Europe and is being used increasingly in the United States. This article provides an overview of cost utility analysis and quality adjusted life years, a commonly used effectiveness measure in CUA when comparing two or more treatments or interventions.
Assuntos
Cuidados Paliativos/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Humanos , Resultado do TratamentoRESUMO
OBJECTIVES: To assess the incidence and economic impact of postoperative ileus (POI) following laparotomy (open) and laparoscopic procedures for colectomies and cholecystectomies in patients receiving postoperative pain management with opioids. METHODS: Using the Premier research database, we retrospectively identified adult inpatients discharged between 2008 and 2010 receiving postsurgical opioids following laparotomy and laparoscopic colectomy and cholecystectomy. POI was identified through ICD-9 diagnosis codes and postsurgical morphine equivalent dose (MED) determined. RESULTS: A total of 138,068 patients met criteria, and 10.3% had an ileus. Ileus occurred more frequently in colectomy than cholecystectomy and more often when performed by laparotomy. Ileus patients receiving opioids had an increased length of stay (LOS) ranging from 4.8 to 5.7 days, total cost from $9945 to $13,055 and 30 day all-cause readmission rate of 2.3 to 5.3% higher compared to patients without ileus. Patients with ileus received significantly greater MED than those without (median: 285 vs. 95 mg, p < 0.0001) and were twice as likely to have POI. MED above the median in ileus patients was associated with an increase in LOS (3.8 to 7.1 days), total cost ($8458 to $19,562), and readmission in laparoscopic surgeries (4.8 to 5.2%). Readmission rates were similar in ileus patients undergoing open procedures regardless of MED. CONCLUSIONS: Use of opioids in patients who develop ileus following abdominal surgeries is associated with prolonged hospitalization, greater costs, and increased readmissions. Furthermore, higher doses of opioids are associated with higher incidence of POI. Limitations are related to the retrospective design and the use of administrative data (including reliance on ICD-9 coding). Yet POI may not be coded and therefore underestimated in our study. Assessment of pre-existing disease and preoperative pain management was not assessed. Despite these limitations, strategies to reduce opioid consumption may improve healthcare outcomes and reduce the associated economic impact.