Analysis of Asthma-Related Costs and Patterns of Resource Utilization in a Managed-Care Population

Objectives: To identify the asthma prevalence rate, the total healthcare and asthma-related treatment costs, and the medical and pharmacy costs associated with different asthma medication usage patterns in a managed-care organisation (MCO). Study design and participants: The medical and pharmacy claims databases from a 400 000 member MCO were used. The medical claims database was searched from 1994 to 1996 for patients having at least one asthma medical claim in either the first or second diagnosis field of the medical claims, and the total healthcare and asthma-related costs were determined. A subpopulation with a more restrictive asthma definition was identified and their costs were also determined. In addition, the patterns of drug treatment were identified. Study perspective: MCO perspective. Results: The mean total healthcare cost of caring for patients with asthma was significant and approximately twice the mean cost of all patients enrolled in the MCO. Using a broad definition of asthma, the mean (± standard deviation) annual total per patient healthcare cost was $US2511 ± 7314 and the annual asthma-related cost was $US679 ± 2247 (1996 values). Using a more restrictive definition of asthma, the mean annual total per patient healthcare cost was $US2653 ± 5268 and the asthma-related cost was $1026 ± 2447. There appeared to be a low overall use of asthma medications, especially anti-inflammatory formulations; <3% of patients with asthma were high users of anti-inflammatory inhalers. Conclusions: Patients with asthma are costly to managed-care organizations. Asthma-related costs constitute a minority (<30%) of the costs of caring for these patients, and under utilization of anti-inflammatory products by patients is widespread. Further research is needed to assess the cost impact of different asthma treatment patterns.     

An Independent Practice Association-Supported Disease Management Program

Background: Disease management has been shown to improve outcomes in patients with chronic diseases such as coronary artery disease (CAD). Yet Independent Practice Associations (IPA) have expressed concern with the promise of disease management (DM) to improve patient outcomes. Managed care initiatives promote the use of case management, DM, and the use of practice guidelines. However, some physicians think that this may impinge on their autonomy. Objective: To demonstrate that integration of an independent DM company in conjunction with an IPA enhances compliance with guideline-recommended medications, reduces morbidity and improves quality of life in patients with CAD. Design: IPA physicians and an independent DM company were contracted with a health plan to provide care to patients with current or recent CAD. The DM company facilitated physician-ordered guideline implementations, provided member education, facilitated medication compliance, and collected all data, using a decision support software system. Collected data included: hospital utilization, quality of life, and reported medications and associated compliance rates. Setting: A large IPA group in the Midwest region of the US. Study Participants: Sixty-five high-risk patients with CAD who were active in the DM program as of April 2, 2002 and in the program for at least 180 days were included in the analysis. Results: The average age of the patients was 73.4 years and 54% were male. The mean duration in the DM program was 10 months (median = 7 months). For those patients (n = 54) with baseline and follow-up mental and physical quality-of-life (QOL) scores, mental QOL scores increased by 2.6% (not significant) and physical QOL scores increased by 11% (p < 0.05). In the 19 patients in the program for 12 months, a trend of reduced hospital admissions was observed. Medication compliance at baseline versus the most recent status for eligible patients was as follows: antihyperlipidemic therapy 59.7% versus 67.7%; β-adrenoceptor antagonist therapy post-myocardial infarction 60.0% versus 66.7%; and antiplatelet therapy was maintained at 98.4%. Conclusions: In spite of the small sample size and relatively short study duration, these results indicate that an integrated DM program may enhance clinical outcomes for patients and reduce hospital admissions.     

An Integrated Model for the Management of Co-Occurring Psychiatric and Substance Disorders in Managed-Care Systems

Objective: To use the System of Objectified Judgement Analysis (SOJA) method for the rational selection of Helicobacter pylori eradication therapies for formulary inclusion. Design: Drug selection for the eradication therapy of H. pylori is made by means of the SOJA method. In this formulary decision-making model, selection criteria for a given class of drugs are prospectively defined and weighted by a panel of experts. The following criteria (relative weight) were used: variability of pharmacokinetics; drug interactions; resistance to antibacterials; efficacy; general adverse effects; complexity of the regimen; acquisition cost and clinical documentation. Only published studies with at least 30 evaluable patients were considered, at least 3 studies had to be available per treatment regimen and efficacy had to be assessed on an intent-to-treat basis. Main outcome measures and results: The regimens containing clarithromycin and an imidazole antibacterial in combination with omeprazole or ranitidine bismutrex showed the highest scores for eradication of H. pylori. The combinations amoxicillin/clarithromycin and omeprazole or lansoprazole showed slightly lower eradication rates and were more costly. The eradication rates obtained with 2-drug regimens were low, resulting in a low overall SOJA score. No quadruple regimens could be included, as none of the regimens fulfilled the inclusion criteria. This was also true for the classical triple therapy with bismuth/metronidazole/tetracycline. Conclusion: The present score is specific for the Netherlands, as Dutch acquisition costs and data on resistance were used. In other countries, with different degrees of imidazole and clarithromycin resistance, other regimens may be more appropriate. The SOJA score will be regularly updated through the internet to include relevant new studies or new successful eradication regimens. The interactive program offers groups of physicians the opportunity to discuss the optimal H. pylori eradication regimen, based on their weighting of the criteria.     

An Empirical Model for the Development of Disease Management Programs in General Practice

Objective: The aim of this research was to develop an empirically derived methodological model for the development of disease management programs in general practice. The model was developed applying the example of hypertension. Methods: Using a rapid appraisal framework, empirical investigations, which included structured panel discussions, face-to-face structured interviews and formal presentations, were conducted to design, test and confirm the disease management model. A broad range of stakeholders were consulted from general practice, other health providers, industry, federal government and consumers. Results: The outcome of the research was a testable definition of disease management for hypertension, and the Australian Disease Management Approach to Hypertension in General Practice (ADAGE) for patients at low to high risk of major cardiovascular events. The central platform of this program is an information, communication technology package for risk assessment and management, plus access to a dietician commissioned by the program and a tailored suite of audiovisual and written material. Conclusion: This study used hypertension to demonstrate a model for the development of theoretically sound disease management models for application in general practice. The ADAGE program is currently under evaluation in a cluster randomized trial of 76 general practices in South Australia and Victoria in both metropolitan and rural settings. It is anticipated that this model will contribute to the development of other disease management programs for addressing chronic disease.     

Management of Acute Otitis Media

Growing concern about the rapid emergence of penicillin-resistant Streptococcus pneumoniae, as well as β-lactamase-mediated resistance among Haemophilus influenzae and Moraxella catarrhalis, has lead to reconsideration of the management of acute Otitis media in children. Acute Otitis media is the most common disorder diagnosed by paediatricians and among the most common indications for which antibacterial agents are prescribed in children.Although there is little consensus regarding the optimal management of children with acute Otitis media, the need for judicious use of antibacterial agents is generally recognised. Several initiatives have been undertaken in an attempt to improve the management practices for this infection. One recent example is the recommendations of the US Drug-Resistant S. pneumoniae (DRSP) Therapeutic Working Group which advocate an accurate diagnosis of acute Otitis media, a step-wise approach to treatment and a role for diagnostic tympanocentesis in children who do not respond to therapy. Based on pharmacokinetic and efficacy data, amoxicillin is recommended as first-line treatment. Cefuroxime axetil, amoxicillin/clavulanic acid and ceftriaxone are recommended as second-line options. Conclusions: Cefuroxime axetil is one of very few oral agents which has proven clinical efficacy against S. pneumoniae, as well as β-lactamase-producing H. influenzae and M. catarrhalis. Although not as palatable as some other oral paediatric formulations, it has significantly better gastrointestinal tolerability than amoxicillin/clavulanic acid, another oral agent with a similar activity profile, and can be administered conveniently in 2 divided daily doses. Cefuroxime axetil is, therefore, an important oral treatment option for children with acute otitis media.     

One-Year Outcomes from a Disease Management Program for Chronic Obstructive Pulmonary Disease

Objective: to present the results of our 1-year, telephonic disease management interventions for 349 patients with mild to severe chronic obstructive pulmonary disease (COPD). Methods: parameters measuring utilization of medical services, days lost from work, and quality-of-life measurements (utilizing the St. George’s Questionnaire) were determined for the 12-month period prior to enrollment of patients and compared with those observed during the 12-month participation in the program. Results: there was a statistically significant reduction in all utilization measurements and a statistically significant improvement in quality of life. Emergency room (ER) visits decreased by 57% (p < 0.001), hospitalizations by 53% (p < 0.001), intensive care unit admissions by 66% (p = 0.001), unscheduled office visits by 67% (p < 0.001), and oral antibacterial bursts by 48% (p < 0.001). Of the 114 employed patients, days missed from work were reduced by 77% (p < 0.001). The total saving from reduction in hospitalizations and ER visits was $US672 000. This was against an approximate cost of the program of $US223 500 (average of $US635 per enrollee). Costs associated with medications and physician visits were not obtained. Conclusions: these outcomes suggest that, with ongoing patient support, the provision of physical rehabilitation, and improved communication between those engaged in the healing process, it is possible to reduce utilization and overall healthcare expenditures and improve the quality of life for a population of patients with moderate to severe COPD. This intervention was both cost effective and medically effective. Our experience suggests that further trials of COPD disease management are warranted.     

Standardized Telephonic Case Management in a Hispanic Heart Failure Population

Background: Heart failure (HF) is as common in Hispanic as it is in non-Hispanic populations. However, there do not appear to be any published reports of HF disease management programs which include Hispanic populations. Objective:To test the effectiveness of a standardized telephonic disease management intervention, Pfizer Inc.’s At Home With Heart Failure?, in decreasing acute care resource use and cost in Hispanic patients with HF. Participants and methods: A factorial design was used to analyze data obtained in a randomized controlled clinical trial. Patients with HF were enrolled in the trial when admitted to hospital, randomized to the intervention or usual care control groups, and followed for 6 months. Of the 358 participants, 93 (26%) were Hispanic (35 in the intervention group, 58 in the usual care group). Data were analyzed to determine if comparable decreases in acute care resource use were evident in Hispanic and non-Hispanic intervention group patients. Intervention: Registered nurses telephoned patients after hospital discharge to provide advice, solve problems, encourage adherence, and facilitate access to needed services. Results: Acute care resource use was lowered as effectively in the Hispanic patients as in the non-Hispanic patients, despite significant between-group differences in education, income, and living situations. When a fully crossed (language by group) analysis was conducted, no significant differences were found between the Hispanic and non-Hispanic intervention groups. However, in most categories there was a trend towards lower resource use in the Hispanic intervention group. The cost of inpatient care was more than $US1000 (2000 values) less in the Hispanic than the non-Hispanic intervention group. Conclusion: The results of this study suggest that Hispanic patients with HF are receptive of, and responsive to, a case management intervention provided in a culturally competent manner, despite differences in cultural views on chronic illness and self-care as discussed in the literature.     

Comparative Studies of Metal Air Pollution by Atomic Spectrometry Techniques and Biomonitoring with Moss and Lichens

Our study was dedicated to the analysis of air pollution level with metals in Dambovita County, Romania; maps of the concentration distributions for air pollutants were drawn; statistical analysis includes calculation of the background concentrations and the contamination factors. The highest values of the contamination factor CF is 63.1 ± 6.63 for mosses samples and 33.12 ± 3.96 for lichens and it indicates extreme contaminations in the surroundings of steel works and an electric plant. The comparison of the distribution maps for Cr, Cu, Fe, Ni, Pb and Zn concentrations enables the identification of the pollution sources, the limits of areas with very high levels of pollution, the comparison of the concentration gradients in some areas and the influence of woodlands on the spread of pollutants through the air.     

Impact of a Migraine Disease Management Program

Objective: To assess the impact of a comprehensive migraine disease management program, as measured by humanistic outcomes measures, conducted in a managed care setting. Design: A prospective comparative study comprised of an intervention and a control group to evaluate the impact of the disease management initiative. Setting: Independent Practice Association (IPA)-type managed care organization. Study participants and main outcomes measures: Study participants resided in adjacent regions (intervention region included Minneapolis, MN, USA and the usual care region included St Paul, MN, USA and adjacent areas in MN, USA) separated by natural geographic barriers. Eligible patients were identified through a review of the Medica plan’s administrative claims database and were asked to complete the Migraine Therapy Assessment Questionnaire (MTAQ), a tool to assess the presence of migraine management issues. Responders (patients completing the MTAQ) who reported ≥2 migraine care risk indicators in the intervention region received the disease management intervention, while all responders in the control region received usual care. Responders in both regions with ≥2 migraine care risk indicators were also asked to complete the Migraine Disability Assessment (MIDAS) questionnaire and the 12-item Short Form Health Survey (SF-12) at baseline. All participants were asked to complete the same instruments at the end of the program as they did at baseline. Interventions: Disease management intervention activities included patient and physician education, as well as a patient feedback report containing migraine care risk indicators, which was sent to the treating physicians. All patients were encouraged to contact their physicians if they reported two or more migraine management issues. Results: A total of 2232 patients with migraine were enrolled in the study (1373 from the intervention region and 859 in the control region). Compared with patients in the control region, patients in the intervention region reported, as measured by MTAQ, significant improvement in migraine symptom relief, more knowledge about potential migraine triggers, a decrease in economic burden, and more satisfaction with migraine treatment. In addition, the change in MIDAS scores from baseline showed a greater shift towards decreasing disability in the intervention group compared with the control group. However, no statistically significant improvement was detected in terms of health status as measured by SF-12. Of the participants in the intervention region who completed the program evaluation survey, 40% indicated that they called or visited their physicians regarding their migraine survey results if it was recommended. For those contacting their physicians, 76% had their medications changed and 75% noted an improvement in relief due to a change in medication. Conclusions: Considering the significant toll of migraine on patients, employers, and the healthcare system, healthcare plans should consider implementing migraine disease management programs to improve migraine care.     

Excess Healthcare Costs Associated with Excess Health Risks in Diseased and Non-Diseased Health Risk Appraisal Participants

Background: Concerns regarding the effectiveness and impact of disease management are largely based on disease compliance measures. Although disease management programs have measured improvements in compliance and quality of life and cost savings from reductions in hospitalizations and emergency room visits, few programs have focused on changing behavioral health risks not directly related to the specific disease. The basic relationship between behavioral health risks and healthcare costs shows that those individuals with more high-risk behaviors are associated with higher healthcare costs compared with those with low-risk behaviors. The concept of excess costs associated with excess risks is a calculation of theoretical maximum percent savings for an entire group assuming everyone reduces to low risk, and changes in healthcare costs follow the changes in risks. Objective: To establish the magnitude of excess healthcare costs associated with excess health risks, given a diagnosed chronic disease. Methods: 135 251 current and retired employees of General Motors Corporation who had completed a Health Risk Appraisal (HRA) were evaluated. Participants were continuously enrolled in traditional or Preferred Provider Organization (PPO) medical plans from 1996 to 1999 and had completed at least one HRA between 1996 and 1998. Results: Those with and without self-reported disease averaged 19.2 and 9.1% excess healthcare costs associated with excess health risks, respectively. However, the magnitude of the impact differed across age groups and diseases. Individuals less than 45 years of age with self-reported disease were most affected by the presence of additional health risks (44% excess costs) while those aged ≥65 years without disease were least affected (8.2% excess costs). Among those with diseases, those with diabetes mellitus and bronchitis/emphysema were most affected (19.2 and 21.0%, respectively). Conclusions: Disease management programs should ideally provide a systematic approach to assist patients with interventions that improve overall health, as well as focusing on disease compliance measures. The implications for disease management programs are that, even given the presence of disease, promoting and/or maintaining low-risk status can result in potential cost savings.     

Prevalence and Management of Anemia Among Patients with Chronic Kidney Disease in a Health Maintenance Organization

Background: Anemia often develops among patients with chronic kidney disease (CKD) and is an important cause of cardiovascular disease among patients with end-stage renal disease (ESRD). Objective: To evaluate the epidemiology and treatment of anemia among patients with CKD by undertaking an analysis of data from one Health Maintenance Organization. Methods: The CKD cohort was comprised of 1658 patients followed between 1 January 1994 and 1 December 1997 who had serum creatinine (SCr) levels above gender-specific norms. The prevalence of anemia and epoetin-α (recombinant human erythropoietin) use was determined, and the association with anemia and kidney function was assessed with multinomial logistic regression analysis. Results: 36% of patients with CKD had anemia, with at least two hematocrit (HCT) values (separated by ≥30 days) lower than the gender-specific norm (<42% for males, <36% for females). Eleven per cent of patients had a lowest HCT value less than the gender-specific norm but ≥33%, 6% had a lowest HCT value 30 to 32.9%, and 19% had a lowest HCT value <30%. The prevalence of anemia was positively correlated with the severity of kidney dysfunction.In the multivariate analysis, the independent relative risk of an HCT value <30% versus no anemia was 84.5, 9.8 and 2.0 for patients with SCr level ≥4.0, 3.0 to 3.9 and 2.0 to 2.9 mg/dl, respectively, compared with patients with SCr level <2.0 mg/dl. Epoetin-α was prescribed for only 7.4% of patients and, more significantly, for only 23% of patients with an HCT value <30%. Even among patients with an HCT value <30% who had received care from a nephrologist, only 66% received epoetin-α. Conclusions: This study demonstrates that the prevalence of anemia among patients with CKD is high and the management of anemia is suboptimal. Suboptimal treatment of anemia during CKD may lead to increased cardiovascular morbidity and cost of care among patients with CKD and ESRD.     

Epoetin Alfa Drug Use Evaluation Using A Software System

Objective: To assess the utility of using a computer software program to determine whether epoetin alfa therapy drug use evaluation (DUE) criteria were met. Study design: Computer software was designed to allow pharmacists to enter patient data such as haematocrit results and iron stores into a database. DUE data were collected upon entry into the study (through medical record review), at 6 months and at 12 months after enrollment for both the treatment and control groups (see Interventions section). The analyses of the 6- and 12-month DUE process and outcome criteria were conducted through an automated algorithm that was part of the software.The DUE evaluation was collected as part of a randomised, prospective, controlled study conducted at 32 sites across the US. Interventions: At least 1 pharmacist at each study site completed a 4-day training session on end-stage renal disease and haemodialysis treatment, principles of anaemia management, use of an epoetin alfa software program, and review of specific DUE criteria. The treatment group consisted of patients managed by a trained pharmacist working in collaboration with a nephrologist being responsible for monitoring, evaluating and recommending epoetin alfa dosage regimens for patients. The control group consisted of patients for whom pharmacists monitored and collected haematocrit data but did not recommend therapy to the nephrologists. Main outcome measures and results: There were no statistically significant differences between patients in both the treatment and control groups with regard to the DUE results. However, the study demonstrated that computer databases can assist in determining whether specific DUE criteria have been met at multiple patient care sites. The computer software applied the same consistent methodology across a broad range of hospital practice sites and thus may have minimised investigator bias or site to site variations in criteria application. Conclusions: Future DUE software algorithms should allow investigators/pharmacists to adjust important parameters such as the criterion threshold, time period of monitoring, ability to code ‘excused’ gaps in data and flexibility to modify criterion parameters.     

The Development of a Tool to Assess Quality of Cost Estimates

Objective: To develop and implement a quality assessment instrument to evaluate cost estimates in economic evaluation studies. Design and setting: The assessment instrument was devised through a consensus process. The instrument was developed in the process of estimating a national set of provincial standard costs for healthcare services in Canada. Participants: All healthcare providers for a variety of services including public health, inpatient acute care, ambulatory care, physicians, pharmaceuticals, blood and ambulance services, and workers’ lost productivity. Main outcome measures: An assessment form which evaluated estimates for the full cost of resources; the appropriate inclusion of resources and resource prices; the degree of detail in the unit of measurement; basis of evidence; and the sample of providers from which cost estimates were generated. Results: When applied to existing cost estimates, a wide variation in quality was observed between service categories and provinces. Inpatient hospital, physician services, and drugs had high quality estimates; public health, nursing home, and home care had lower quality estimates. Conclusions: This quality assessment instrument can be used to target deficiencies in cost estimates and to identify administrative units which are leaders in the field, and hence which can serve as role models for further development of these data.