A Longitudinal Analysis of Outcomes Associated with Abciximab and Eptifibatide in a Consecutive Series of 3074 Percutaneous Coronary Interventions

Background:  Although the efficacy of platelet glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) in reducing complication rates during percutaneous coronary intervention (PCI) is well established, comparative studies assessing currently approved agents as administered in current practice are limited. We studied the clinical and length of stay (LOS) outcomes of patients undergoing PCI who received either abciximab or eptifibatide.
Methods:  All patients undergoing elective, urgent, or emergency PCI at Mayo Clinic Rochester between November 17, 2000 and August 31, 2004 who received either abciximab or eptifibatide were included. Clinical, angiographic, and follow-up data were prospectively recorded in the Mayo Clinic PCI Registry; administrative data recorded LOS. We used logistic and Cox proportional hazard models to estimate the risk of adverse events and generalized linear modeling to predict LOS. Propensity score and standard risk adjustments were used to account for baseline differences.
Results:  A total of 2123 PCI patients received eptifibatide and 951 received abciximab. The adjusted odds ratio for in-hospital death and myocardial infarction (MI) with eptifibatide was 0.80 (95% CI 0.56–1.14, P  = 0.21) versus abciximab. Adjusted hazard ratios for death and MI and for death, MI, or target vessel revascularization during a median follow-up of 24.6 months were 0.84 (95% CI 0.68–1.02, P  = 0.08) and 0.95 (95% CI 0.81–1.11, P  = 0.53), respectively. Adjusted postprocedural LOS was similar at 3.4 days.
Conclusion:  This large observational study found no evidence of a clinical or LOS advantage to physician choice of either abciximab or eptifibatide during PCI in contemporary practice.     

Cost-Effectiveness of Primary versus Secondary Prophylaxis with Pegfilgrastim in Women with Early-Stage Breast Cancer Receiving Chemotherapy

Objective:  Prophylaxis with granulocyte colony-stimulating factor (G-CSF) reduces the risk of febrile neutropenia (FN) in patients receiving myelosuppressive chemotherapy. We estimated the incremental cost-effectiveness of G-CSF pegfilgrastim primary (starting in cycle 1 and continuing in subsequent cycles of chemotherapy) versus secondary (only after an FN event) prophylaxis in women with early-stage breast cancer receiving myelosuppressive chemotherapy with a ≥20% FN risk.
Methods:  A decision-analytic model was constructed from a health insurer's perspective with a lifetime study horizon. The model considers direct medical costs and outcomes related to reduced FN and potential survival benefits because of reduced FN-related mortality. Inputs for the model were obtained from the medical literature. Sensitivity analyses were conducted across plausible ranges in parameter values.
Results:  The incremental cost-effectiveness ratio (ICER) of pegfilgrastim as primary versus secondary prophylaxis was $48,000/FN episode avoided. Adding survival benefit from avoiding FN mortality yielded an ICER of $110,000/life-year gained (LYG) or $116,000/quality-adjusted life-year (QALY) gained. The most influential factors included FN case-fatality, FN relative risk reduction from primary prophylaxis, and age at diagnosis.
Conclusions:  Compared with secondary prophylaxis, the cost-effectiveness of pegfilgrastim as primary prophylaxis may be equivalent or superior to other commonly used supportive care interventions for women with breast cancer. Further assessment of the direct impact of G-CSF on short- and long-term survival is needed to substantiate these findings.     

Phlebotomy teams reduce blood-culture contamination rate and save money

OBJECTIVE: To determine the extent of resource utilization due to contaminated blood cultures. DESIGN: Case-control retrospective analysis. Twenty-three patients who had contaminated blood cultures were matched by age, underlying diseases, and discharge diagnoses with 23 patients who had negative blood cultures. SETTING: St Luke's Medical Center, a community teaching hospital in Cleveland, Ohio. The phlebotomy team was eliminated in November 1993 to reduce the costs. RESULTS: Blood cultures drawn by the phlebotomy team had a lower contamination rate compared with those drawn by nonphlebotomists (2.6% vs 5.6%). Patients with contaminated blood cultures were compared to those with negative blood cultures. The following parameters were found to be statistically significant: total hospital length of stay (LOS; 13.9 vs 5.5 days; P = .002), postculture LOS (8.9 vs 4.6; P = .01), postculture number of days on antibiotics (5.9 vs 2.9; P = .03), vancomycin use (9 vs 2 patients; P = .03), postculture cost of antibiotics ($762 vs $121; P = .004), and postculture hospital cost per patient ($10,515 vs $4,213; P = .001). CONCLUSIONS: This study demonstrated a substantial increase in resource utilization in our hospital due to contaminated blood cultures. The reinstitution of a phlebotomy team could be a cost-effective solution with savings between $950,000 and $1.5 million per year for our hospital.     

The long-term cost-effectiveness of once-weekly semaglutide 1 mg vs. dulaglutide 3 mg and 4.5 mg in the UK

Aims

Once-weekly semaglutide and dulaglutide represent two highly efficacious treatment options for type 2 diabetes. A recent indirect treatment comparison (ITC) has associated semaglutide 1 mg with similar and greater improvements in glycated haemoglobin (HbA1c) and body weight, respectively, vs. dulaglutide 3 mg and 4.5 mg. The present study aimed to evaluate the long-term cost-effectiveness of semaglutide 1 mg vs. dulaglutide 3 mg and 4.5 mg in the UK.

Materials and methods

The IQVIA CORE Diabetes Model (v9.0) was used to project outcomes over patients’ lifetimes. Baseline cohort characteristics were sourced from SUSTAIN 7, with changes in HbA1c and body mass index applied as per the ITC. Modelled patients received semaglutide or dulaglutide for 3 years, after which treatment was intensified to basal insulin. Costs (expressed in 2020 pounds sterling [GBP]) were accounted from a healthcare payer perspective.

Results

Semaglutide 1 mg was associated with improvements in quality-adjusted life expectancy of 0.05 and 0.04 quality-adjusted life years (QALYs) vs. dulaglutide 3 mg and 4.5 mg, respectively, due to a reduced incidence of diabetes-related complications with semaglutide. Direct costs were estimated to be GBP 76 lower and GBP 8 higher in the comparisons with dulaglutide 3 mg and 4.5 mg, respectively. Overall outcomes were similar, but favoured semaglutide, and based on modelled mean outcomes it was considered dominant vs. dulaglutide 3 mg and associated with an incremental cost-effectiveness ratio of GBP 228 per QALY gained vs. dulaglutide 4.5 mg.

Conclusions

Semaglutide 1 mg represents a cost-effective treatment vs. dulaglutide 3 mg and 4.5 mg for type 2 diabetes from a healthcare payer perspective in the UK.

     

Effect of nutritional education and dietary counselling on body weight in HIV-seropositive South Africans not receiving antiretroviral therapy

Background Unintentional weight loss of > 10% contributes to morbidity and mortality in HIV-infected patients. In poorer developing countries, cost-effective options to promote weight gain are extremely limited.
Methods We conducted a pilot study of the effect of nutritional education and dietary counselling on body weight in 90 HIV/AIDS patients. Education entailed principles of healthy eating, socioeconomics of nutrition, food safety, and symptom-related dietary guidelines. Other clinical parameters examined for potential impact on body weight included age, sex, CD4+ lymphocyte count, presence of complicating infections, concomitant medications, vitamin use, and nutritional supplementation. No patients received antiretroviral therapy.
Results At study end (mean follow-up, 4.2 months) body weight compared to baseline was greater in study subjects than in controls ( P  < 0.01); stable or increasing weight was seen in 73% of study patients. Weight gain (≥ 1 kg) occurred in 53% of counselled patients (mean = 3.5 kg; range 1–11 kg) vs. 21% of matched controls (mean = 2.0 kg; range 1–3 kg) ( P  < 0.03). Nutritional counselling was found to offset the adverse effects of gastrointestinal tract or systemic infection (especially in patients with CD4+ counts < 200 cells mm^–3).
Conclusion In low-resource areas, culturally and economically relevant nutritional education and dietary counselling are simple yet effective means of stabilizing or increasing body weight in HIV-infected patients.     

The Direct Medical Costs of Undiagnosed Chronic Obstructive Pulmonary Disease

Objective:  To estimate the costs of undiagnosed chronic obstructive pulmonary disease (COPD) by describing inpatient, outpatient, and pharmacy utilization in the years before and after the diagnosis.
Methods:  A total of 6864 patients who were enrolled in the Lovelace Health Plan for at least 12 months during the study period (January 1, 1999 through December 31, 2004) were identified. The first date that utilization was attributed to COPD was considered the first date of diagnosis. Each COPD case was matched to up to three age- and sex-matched controls. All utilization and direct medical costs during the study period were compiled monthly and compared based on the time before and after the initial diagnosis.
Results:  Total costs were higher by an average of $1182 per patient in the 2 years before the initial COPD diagnosis, and $2489 in the 12 months just before the initial diagnosis, compared to matched controls. Most of the higher cost for undiagnosed COPD was attributable to hospitalizations. Inpatient costs did not increase after the diagnosis was made, but approximately one-third of admissions after the diagnosis were attributed to respiratory disease. Outpatient and pharmacy costs did not differ substantially between cases and matched controls until just a few months before the initial diagnosis, but remained 50% to 100% higher than for controls in the 2 years after diagnosis.
Conclusions:  Undiagnosed COPD has a substantial impact on health-care costs and utilization in this integrated managed care system, particularly for hospitalizations.     

Cost-Utility Analysis of Eprosartan Compared to Enalapril in Primary Prevention and Nitrendipine in Secondary Prevention in Europe—The HEALTH Model

Objective:  To investigate the cost-utility of eprosartan versus enalapril (primary prevention) and versus nitrendipine (secondary prevention) on the basis of head-to-head evidence from randomized controlled trials.
Methods:  The HEALTH model (Health Economic Assessment of Life with Teveten^® for Hypertension) is an object-oriented probabilistic Monte Carlo simulation model. It combines a Framingham-based risk calculation with a systolic blood pressure approach to estimate the relative risk reduction of cardiovascular and cerebrovascular events based on recent meta-analyses. In secondary prevention, an additional risk reduction is modeled for eprosartan according to the results of the MOSES study ("Morbidity and Mortality after Stroke—Eprosartan Compared to Nitrendipine for Secondary Prevention"). Costs and utilities were derived from published estimates considering European country-specific health-care payer perspectives.
Results:  Comparing eprosartan to enalapril in a primary prevention setting the mean costs per quality adjusted life year (QALY) gained were highest in Germany (€24,036) followed by Belgium (€17,863), the UK (€16,364), Norway (€ 13,834), Sweden (€ 11,691) and Spain (€ 7918). In a secondary prevention setting (eprosartan vs. nitrendipine) the highest costs per QALY gained have been observed in Germany (€9136) followed by the UK (€6008), Norway (€1695), Sweden (€907), Spain (€−2054) and Belgium (€−5767).
Conclusions:  Considering a €30,000 willingness-to-pay threshold per QALY gained, eprosartan is cost-effective as compared to enalapril in primary prevention (patients ≥50 years old and a systolic blood pressure ≥160 mm Hg) and cost-effective as compared to nitrendipine in secondary prevention (all investigated patients).     

Cost-Effectiveness of Posaconazole versus Fluconazole or Itraconazole in the Prevention of Invasive Fungal Infections among Neutropenic Patients in the United States

Objectives:  Clinical trial data indicate that posaconazole is superior to fluconazole (FLU) or itraconazole (ITRA) in preventing invasive fungal infections (IFIs) among neutropenic patients. Our objective was to assess the cost-effectiveness of posaconazole versus FLU or ITRA for prevention of IFIs among neutropenic patients.
Methods:  We used modeling techniques to assess the cost-effectiveness of posaconazole versus FLU or ITRA in the prevention of IFIs among patients with acute myelogenous leukemia (AML) or myelodysplastic syndromes (MDS) and chemotherapy-induced neutropenia. The probabilities of experiencing an IFI, IFI-related death, and death from other causes over 100 days of follow-up were estimated from clinical trial data. Long-term mortality, drug costs, and IFI treatment costs were obtained from secondary sources.
Results:  Posaconazole is associated with fewer IFIs per patient (0.05 vs. 0.11) relative to FLU or ITRA over 100 days of follow-up, and lower discounted costs ($3900 vs. $4500) and increased life-years (2.50 vs. 2.43 discounted) over a lifetime horizon. Results from a probabilistic sensitivity analysis indicate that there is a 73% probability that posaconazole is cost saving versus FLU or ITRA and a 96% probability that the incremental cost-effectiveness ratio for posaconazole is at or below $50,000 per life-year saved.
Conclusions:  We conclude that posaconazole is very likely to be a cost-effective alternative to FLU or ITRA in the prevention of IFIs among neutropenic patients with AML and MDS, and may result in cost savings.     

抗菌药物治疗链球菌的蒙特卡洛模拟研究

目的 借助全国血流感染耐药监测联盟(BRICS)平台收集的链球菌属细菌,评价头孢曲松、左氧氟沙星及莫西沙星给药方案,以期为临床医生合理用药提供依据.方法 采用琼脂稀释法测定头孢曲松、左氧氟沙星及莫西沙星药物敏感情况,应用蒙特卡洛模拟方法研究三种药物不同给药方案的达标概率和累计反应分数(CFR).结果 最低抑菌浓度(MI...     

Economic Evaluation of Atorvastatin for Prevention of Recurrent Stroke Based on the SPARCL Trial

Objectives:  This study evaluated the economic implications of results obtained by the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.
Methods:  To enable long-term projection of the trial results, a discrete event simulation of the course of clinical care after a recent stroke or transient ischemic attack (TIA) was developed. It generates pairs of identical patients; both receive usual care, one receives atorvastatin in addition. Their clinical course is simulated based on their risk of stroke, cardiovascular events, and case fatality rates taken from SPARCL, life expectancy from Saskatchewan Health data, and utility weights from literature. Costs, from a US health-care payer perspective in 2005 US dollars, were estimated for a within-trial 5-year period; survival and quality-adjusted life-years (QALYs) were extrapolated over a patient's lifetime; all discounted at 3%/year.
Results:  The prevention of stroke, coronary, and other cardiovascular events expected with atorvastatin translates to mean gains of 0.155 life-years gained and 0.172 QALYs per patient over their lifetime. Reducing associated medical costs ($8405 vs. $11,237) but increasing drug costs ($13,984 vs. $8752) results in net $2400/patient, or $13,916/QALY gained. Probabilistic sensitivity analysis indicates no simulations yield ratios above $50,000/QALY.
Conclusion:  Prescribing atorvastatin for patients with prior stroke or TIA is expected to provide health benefits at an acceptable cost in the United States.     

PCV9 Study of Hypertensive Prescribing Practices

This study compared the use and outcomes associated with intravenous dilitiazem and/or intravenous digoxin as a primary therapy in patients admitted for treatment of atrial fibrillation.
METHODS: A retrospective database analysis was conducted with data from seven academic medical centers. The use of intravenous diltiazem, digoxin, or both, in patients admitted for treatment of atrial fibrillation between January 1993 and July 1996 was analyzed. SAS data sets were created to combine financial records with clinical files. The primary outcomes of interest measured were the length of hospital stay (LOS), total hospital cost, hospital mortality, and 30-day readmission rates.
RESULTS: A total of 107 patients was identified in the University Health System Consortium (UHC) clinical database (CDB) with admissions for treatment of atrial fibrillation. 46, 41, and 20 patients received intravenous dilitiazem, digoxin, or both agents, respectively. Hospital mortality rates were not different among patients. The most common concomitant disease states included congestive heart failure (n = 28) and hypertension (n = 9). The mean LOS was 4.11, 8.34, and 9.15 days for patients receiving diltiazem, digoxin, or both agents, respectively. The mean total cost of hospitalization was $4,890, $11,063 and $13,547 for patients receiving diltiazem, digoxin, or both agents, respectively. More patients receiving both agents were readmitted within 30 days (25%) as compared to patients receiving only diltiazem (8%) or digoxin (22%).
CONCLUSION: Intravenous diltiazem was associated with a decreased LOS, decreased total hospital costs, a decreased 30-day readmission rate and no difference in mortality in comparison with intravenous digoxin. Therefore, intravenous diltiazem warrants further consideration as a replacement for intravenous digoxin in the cost-effective management of atrial fibrillation.     

How Do Type 2 Diabetes Mellitus-Related Chronic Complications Impact Direct Medical Cost in Four Major Cities of Urban China?

Objective:  The purpose of this study was to evaluate the direct medical costs of type 2 diabetes mellitus with or without complications, and to determine the economic impact of complications on type 2 diabetic patients.
Methods:  We performed a cross-sectional study of prevalent type 2 diabetes carried out in four major cities of China. The study populations were 1530 outpatients and 524 inpatients from clinics or wards of a total of 20 hospitals, using a two-phase subject enrolment process, by face-to-face interview with a unique questionnaire.
Results:  The annual direct medical cost per patient was estimated to be 4800 Chinese Yuan (CNY) in median or 10,164 CNY in mean. There is a difference between annual direct medical costs for patients with or without complications (6056 vs. 3583 CNY; P  < 0.001). It is also significantly different for the pay-out-of-pocket proportions ( P  = 0.015) between the patients with (44.6%) and without complications (40.4%). The direct medical cost varied significantly among the four cities ( P  < 0.001). Patients who simultaneously suffered microvascular and macrovascular diseases had higher direct medical cost (7600) than those with macrovascular (6000) ( P  = 0.012) and microvascular disease (5364) ( P  < 0.001), and those without both (3600) ( P  < 0.001). The correlation was statistically significant between the number of complications and direct medical costs ( P  < 0.001).
Conclusions:  The high economic burden raised by diabetes and its complications challenges the Chinese health-care system. It implicates an urgent need of intervention to prevent the development of long-term complications among the diabetic population, especially on the development of complications in high-cost body system.     

Resource Utilization and Costs of Schizophrenia Patients Treated with Olanzapine versus Quetiapine in a Medicaid Population

ObjectiveCompare annual health-care costs and resource utilization associated with olanzapine versus quetiapine for treating schizophrenia in a Medicaid population.MethodsAdult schizophrenia patients were selected from deidentified Pennsylvania Medicaid claims database (1999–2003). Included patients were continuously enrolled and initiated with olanzapine or quetiapine monotherapy after a 90-day washout period. Treatment costs were calculated for 1-year post-therapy initiation and inflation adjusted to year 2003. To control for selection bias, olanzapine and quetiapine patients were 1:1 matched using an optimal matching algorithm on propensity score, which was generated using logistic regression controlling for demographics, prior drug therapy, utilization, and costs. Treatment costs for the matched cohorts were compared directly, as well as using a difference-in-difference analysis.ResultsA total of 6929 patients treated with olanzapine and 2321 with quetiapine met inclusion criteria. Quetiapine patients appeared more severe at baseline. After propensity score matching, 2321 patient pairs had similar baseline characteristics, including total costs. Compared with matched quetiapine patients, for the 1-year postindex period, olanzapine patients had similar drug costs ($6131 vs. $6014, P = 0.326), lower medical costs ($9897 vs. $11,218, P = 0.0128), and lower total health-care costs ($16,028 vs. $17,232, P = 0.0279). Lower psychiatric hospitalization costs account for most of the total cost difference. Difference-in-difference regression analysis confirmed olanzapine's economic advantage. Further adjusting for baseline variations, the total cost advantage of olanzapine patients was $962 (P = 0.032), and was mostly because of reduced psychiatric hospitalization costs of $992 (P = 0.004).ConclusionSchizophrenia patients treated with olanzapine had lower total costs than quetiapine patients, mostly attributable to reductions in psychiatric hospitalization costs.     

Deterioration of Quality of Life of High-Risk Breast Cancer Patients Treated with High-Dose Chemotherapy: The PEGASE 01 Quality of Life Study

Objective:  The aim of this study was to compare the quality of life (QOL) of high-risk breast cancer patients included in a randomized clinical trial (PEGASE 01) comparing conventional chemotherapy versus adding an additional high-dose chemotherapy (HDC) cycle with blood stem cell support.
Methods:  A total of 314 patients were included in the clinical trial. QOL evaluations were available for 199 patients. QOL was assessed over a 1-year follow-up period, using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30. The results were analyzed using a linear mixed-effects model.
Results:  Toxicity of HDC has a strong negative impact on patients' QOL during the treatment phase. This negative impact tended to last longer in the HDC group, as for most of the QLQ-C30 scales, the QOL scores of HDC patients tend to improve at a slower rate than that of patients receiving standard chemotherapy. In particular, physical functioning remains deteriorated 1 year after inclusion for HDC patients comparatively to conventional chemotherapy patients (85.99 vs. 76.65, P  = 0.021), and the pain score was still higher in the HDC group at that time (28.32 vs. 15.97, P  = 0.004).
Conclusion:  HDC has a negative impact on QOL even after treatment phase. In the absence of an overall survival benefit of using HDC for high-risk breast cancer patients, QOL studies with a longer follow-up play an important role in informing the complex trade-off implied by HDC between higher toxicity, reduced risk of relapse, and QOL decrease after the active phase of treatment.     

Utility Estimates for Decision–Analytic Modeling in Chronic Heart Failure—Health States Based on New York Heart Association Classes and Number of Rehospitalizations

Objectives:  For economic evaluations of chronic heart failure (CHF) management strategies, utilities are not currently available for disease proxies commonly used in Markov models. Our objective was to estimate utilities for New York Heart Association (NYHA) classification and number of cardiovascular rehospitalizations.
Methods:  EuroQol 5D data from the Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study trial were used to estimate utilities as a function of NYHA classification and number of cardiovascular rehospitalizations.
Results:  In multivariate regression analyses adjusted for age (60 years), female sex and absence of further comorbidities, utilities for NYHA classes I–IV were 0.90, 0.83, 0.74, and 0.60 ( P -value < 0.001 for trend). For cardiovascular rehospitalizations 0, 1, 2 and ≥3, the associated utilities were 0.88, 0.85, 0.84, and 0.82 ( P -value < 0.001 for trend).
Conclusions:  NYHA class and number of cardiovascular rehospitalizations are established proxies for CHF progression and can be linked to utilities when used as health states in a Markov model. NYHA class should be used when feasible.     

Cost-Effectiveness of Drug-Eluting Stents in a US Medicare Setting: A Cost-Utility Analysis with 3-Year Clinical Follow-Up Data

Background:  There is only limited information about cost-effectiveness of drug-eluting compared with bare metal stents (BMS) over a time horizon of more than 1 year.
Methods and Results:  We developed a Markov model based on clinical outcome data from a meta-analysis including 17 randomized controlled trials comparing drug-eluting versus BMS with a minimum follow-up of 1 (n = 8221) and a maximum follow-up of 3 years (n = 4105) in patients with chronic coronary artery disease. Costs were obtained as reimbursement rates for diagnosis related groups from the US Centers for Medicare and Medicaid Services. All costs and effects were discounted at 3% annually. All costs are reported in US dollars of the financial year 2007. The incremental effects are 0.002 (95% confidence interval −0.039 to 0.041) quality-adjusted life-years (QALYs) for the sirolimus- and −0.001 (−0.040 to 0.038) QALYs for the paclitaxel-eluting stents (PES). The incremental costs are $2790 for the sirolimus- and $3838 for the PES. The incremental cost-effectiveness ratio is >$1,000,000 per QALY for the sirolimus-eluting stent. PES are dominated by BMS (i.e., less effective and more costly). Among various sensitivity analyses performed, the model proved to be robust.
Conclusions:  Our analysis from a US Medicare perspective suggests that drug-eluting stents are not cost-effective compared with BMS when implanted in unselected patients with symptomatic ischemic coronary artery disease.     

Relationship of Nutritional Status to Length of Stay, Hospital Costs, and Discharge Status of Patients Hospitalized in the Medicine Service

Objective This study was conducted to determine the relationship, if any, between nutritional status, length of stay (LOS) in hospital, discharge placement, readmission rates, and hospital costs and charges in patients hospitalized in the medicine service.Design Data regarding medical diagnosis, LOS, hospital costs, charges, discharge destination, and readmission rates were collected prospectively from medical records and through patient interviews on patients admitted to the medical service who were classified to be at risk or not at risk for malnutrition on the basis of established criteria (weight for height <75% ideal body weight, admission serum albumin level <30 g/L, or ≥10% unintentional weight loss within 1 month before admission).Subjects All patients admitted directly to any of three medicine units during December 1994 who met study criteria were included in the study. Off-service patients, transfer patients, and patients discharged before screening (usually admitted and discharged within 72 hours) were excluded. Data were collected on 173 patients.Statistical analysis performed At-risk and not at-risk patients were compared for LOS, costs and reimbursement, and discharge placement (to home, to home with home health care services, or to another facility for further care). Two sample t tests and α survival analysis technique were used to compare continuous variables between the two study cohorts. Nonparametric tests were used for LOS and readmission data. χ² Tests were used for categoric variables. An a level of 0.05 was used throughout to determine statistical significance.Results Median LOS in the not-at-risk population (n=56) was significantly greater than in the not-at-risk population (n= 117): 6 days (25th percentile=4 days, 75th percentile-8 days) vs 4 days (25th percentile=3 days, 75th percentile=7 days) (P<0.01).Mean hospitalization cost per patient was also higher in the at-risk group ($6,196 vs $4,563, P<0.02). Readmission rate per month of follow-up was not significantly different. At-risk patients were significantly less likely to be discharged home with self-care (23 [41%] vs 77 [66%], P<0.05). At-risk patients were significantly more likely to use home health care service than not-at-risk patients (17 [31%] vs 14 or [12%], P<0.001).Applications Patients at risk for malnutrition had significantly higher LOS, costs, and home health care needs, despite the fact that 51, or 91%, received nutrition intervention while hospitalized. Further research should explore the use of nutrition screening and intervention before, during, and after hospitalization to ensure that appropriate nutrition intervention, as indicated by medical patients’ clinical condition and nutritional risk status, is initiated and continued.     

The Clinical and Economic Burden of Nonadherence with Antihypertensive and Lipid-Lowering Therapy in Hypertensive Patients

Objective:  We sought to determine lifetime costs, morbidity, and mortality associated with varying adherence to antihypertensive and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statin) therapy in a hypertensive population.
Methods:  A model was constructed to compare costs and outcomes under three adherence scenarios: no treatment, ideal adherence, and real-world adherence. Simulated patients' characteristics matched those of participants in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid-Lowering Arm and event probabilities were calculated with Framingham Heart Study risk equations. The real-world adherence scenario employed adherence data from an observational study of a US population; risk reductions at each level of adherence were based on linear extrapolations from clinical trials. Outputs included life expectancy, frequencies of primary and secondary coronary heart disease and stroke, and direct medical costs in 2006 US$. The incremental cost per life-year gained and incremental cost per event avoided were calculated comparing the three adherence scenarios.
Results:  Mean life expectancy was 14.73 years (no-treatment scenario), 15.07 (real-world adherence), and 15.49 (ideal adherence). The average number of cardiovascular events per patients was 0.738 (no treatment), 0.610 (real-world adherence), and 0.441 (ideal adherence). The incremental cost of real-world adherence versus no treatment is $30,585 per life-year gained, and ideal adherence versus real-world adherence is $22,121 per life-year gained.
Conclusions:  Hypertensive patients taking antihypertensive and statin therapy at real-world adherence levels can be expected to receive approximately 50% of the potential benefit seen in clinical trials. Depending on its cost, the incremental benefits of an effective adherence intervention program could make it an attractive value.