Medical cost savings from pentoxifylline therapy in chronic occlusive arterial disease

This article assesses the direct medical cost savings associated with therapeutic dosages of pentoxifylline therapy compared with lower dosages in treating chronic occlusive arterial disease (COAD). The savings accrue from elimination of invasive diagnostic measures or a number of surgical procedures received by patients with COAD during hospital admissions. Findings are based on a secondary analysis of results presented in a previously published report of a population based historical cohort study. Patients in this study were severely enough afflicted by the disease that most were under the care of vascular specialists and many underwent surgery to restore normal blood flow. Costs are based on charges from Medicare expenditures in 4 US states in 1989. A case-mix adjustment procedure was applied and a sensitivity analysis was conducted on key assumptions and variables in the cost savings model. Pentoxifylline therapy reduced average hospital costs per patient by $US1173 per year (1989 dollars). After further adjustment for the costs of outpatient visits, other related drugs and the drug acquisition cost, an overall saving of $US965 would still be realised with a patient who received the full therapeutic dose of pentoxifylline. Sensitivity analysis suggests total annual direct medical cost savings between $US69 and $US3090 per patient. Hence, under the most plausible assumptions regarding choice of procedures, study design and patient population, and considering the possibility that diagnostic and surgical costs are delayed but not prevented, pentoxifylline therapy substantially reduces direct medical costs.     

Antiischemic therapy in patients with coronary heart disease living in long-term care. Systematic Assessment of Geriatric Drug Use by Epidemiology (SAGE) Group.

We evaluated antiischemic therapy in elderly nursing home residents with a diagnosis of coronary heart disease (CHD) using a population-based data base with over 300,000 residents (1992-1995) of all Medicare/Medicaid-certified nursing homes of five states. We identified 72,263 patients age 65 years or older with a diagnosis of CHD. We examined data collected with the federally mandated Minimum Data Set, drug information, and Medicare hospital claims. Antiischemics were defined as beta-adrenergic blockers, long-term nitrates, and calcium channel blockers. We determined factors associated with use of the drugs by logistic regression. Antiischemic therapy was inversely related to age and cognitive and physical functioning, but positively associated with recent hospitalization and concomitant cardiovascular diseases. beta-Adrenergic blockers were least likely to be administered regardless of age, gender, or cognitive or physical function. We conclude that antiischemic therapy in nursing home residents may not be optimal.     

Use of psychotropic drugs in elderly nursing home residents with and without dementia in Helsinki, Finland

OBJECTIVE: Use of psychotropic medication is very common in nursing home residents. Our objective was to describe the use of psychotropic drugs in all long-term nursing home residents > or =65 years of age with and without dementia in Helsinki, Finland. METHOD: The study was a cross-sectional assessment of the nursing home population. The residents' health status was assessed and data on their demographic factors, health and medication use were collected from medical charts in February 2003. RESULTS: Of all nursing home residents in Helsinki, 82% (n = 1987) participated in the study. The nursing home residents' mean age was 83.7 (SD 7.7) years, 80.7% were female, and 69.5% were diagnosed with dementia. The mean number of drugs [corrected] given regularly was 7.9 (SD 3.6) per day per resident[corrected] Of the participants, 79.7% were regularly taking psychotropic medication. Conventional antipsychotics were administered to 18.9% of residents and atypical antipsychotics to 27.0%. Of the residents, 26.7% were on selective serotonin reuptake inhibitors (SSRIs), 3.1% on tricyclic antidepressants and 17.6% on other antidepressants. Altogether, 44.6% of residents were taking one or more antidepressant. More than a quarter (26.3%) were taking at least one anxiolytic drug. Hypnotics were used by 27.5%. However, only moderate dosages of psychotropic drugs were being taken. Only 10.4% of individuals with dementia were regularly taking cholinesterase inhibitors and four residents were taking memantine. CONCLUSIONS: Use of psychotropic drugs is very common in nursing homes in Helsinki, Finland, with four of five nursing home residents regularly receiving psychotropic drugs. Only one in ten residents were receiving cholinesterase inhibitors. Physicians caring for nursing home residents require further education on the benefits and adverse effects of psychotropic drugs in frail elderly people.     

Adverse events among nursing home residents with Alzheimer's disease and psychosis

PURPOSE: The objective of this study was to quantify rates of adverse events in a high-risk multi-morbid population of institutionalized patients with Alzheimer's disease (AD). METHODS: We conducted a retrospective cohort study among nursing home residents diagnosed with AD and psychosis during January 1998 to October 1999. Using the Medicare Minimum Data Set (MDS) and Medicare inpatient claims (ICD-9 codes), 7728 nursing home residents aged 55-95 years with AD and psychosis were identified for study. Potential adverse events of interest were identified from the MDS and Medicare inpatient claims (ICD-9 codes). We estimated the incidence rate (IR) and 95% confidence interval (CI) for each adverse event during a 2-year follow-up period. RESULTS: Of the 7728 residents studied, nearly 30% were considered 'dependent' by the activities of daily living (ADL) score and approximately 15% exhibited severe cognitive impairment at baseline. At least 90% had comorbid psychiatric disorders. The most common adverse event was accidental injury, occurring at a rate of 97.7 per 100 person-years (95%CI = 94.7-100.7). Other common adverse events were death (IR = 44.6/100 person-years; 95%CI = 42.9-46.4), infection (IR = 41.8/100 person-years; 95%CI = 39.7-43.8), pain (IR = 43.5/100 person-years; 95%CI = 41.2-45.9), anorexia (41.3/100 person-years; 95%CI = 39.1-43.6), and weight change (IR = 40.2/100 person-years; 95%CI = 38.7-41.7). CONCLUSIONS: This information on the occurrence of adverse outcomes among nursing home patients with AD and psychosis provides useful context for any safety event observed among patients treated for psychosis.     

Dose and cost comparison of erythropoietic agents in the inpatient hospital setting.

PURPOSE: The inpatient dosing patterns and treatment costs in cancer and predialysis chronic kidney disease (CKD) patients treated with erythropoietic agents from a hospital pharmacy perspective were studied. METHODS: An analysis of electronic inpatient records from the Premier Perspective comparative hospital database was conducted. Study participants were identified through hospitalizations recorded between July 2002 and March 2005 from over 500 hospitals nationwide. Adult patients with an admitting diagnosis of cancer or predialysis CKD and treated with epoetin alfa or darbepoetin alfa during hospitalization were included. Patients who had received renal dialysis or both agents during a hospitalization were excluded. Wholesale acquisition costs from September 2006 were used to calculate drug costs. RESULTS: A total of 25,645 hospitalized patients with cancer (22,873 received epoetin alfa; 2,772 received darbepoetin alfa) and 66,822 hospitalized patients with CKD (60,079 received epoetin alfa; 6,743 received darbepoetin alfa) were identified. The mean cumulative dose per hospitalization resulted in dose ratios of 245:1 and 242:1 (units epoetin alfa:micrograms darbepoetin alfa) for cancer and CKD patients, respectively. On the basis of the cumulative dose per hospitalization, drug costs for darbepoetin alfa-treated patients were approximately 50% higher than drug costs for epoetin alfa-treated patients for both oncology and CKD patients. CONCLUSION: Epoetin alfa was associated with less cost compared with darbepoetin alfa for treating inpatients with cancer or CKD. Further research including the patients' clinical outcomes is necessary to determine the true pharmacoeconomic differences between the two agents.     

Healthcare costs of patients with heart failure treated with torasemide or furosemide

OBJECTIVE: To compare the direct healthcare costs of patients with congestive heart failure (CHF) prescribed torasemide (torsemide) or furosemide (frusemide). DESIGN AND SETTING: As part of a prospective, randomised, nonblind study, we assessed the effects of torasemide and furosemide on readmission to hospital in 193 patients treated for CHF at a US urban public healthcare system. We also calculated total direct healthcare costs for the 2 drugs. The perspective of the analysis was that of the healthcare system. Healthcare charge and utilisation data, demographic information, and health status data were obtained from an electronic database containing data for all patients treated within the healthcare system. PATIENTS AND PARTICIPANTS: Upon admission to the hospital, patients were eligible if they had evidence of left ventricular systolic dysfunction, were at least 18 years old, and were receiving furosemide. INTERVENTION: Inpatients were randomised to either torasemide or furosemide treatment for 1 year. MAIN OUTCOME MEASURES AND RESULTS: Patients treated with torasemide had fewer hospital admissions than those treated with furosemide [18 vs 34% for CHF (p = 0.013) and 38 vs 58% for any cardiovascular cause (p = 0.005)]. In the torasemide group, expected annual hospital costs per patient were lower for CHF admissions (by $US1054; 1998 values) and for all cardiovascular admissions (by $US1545) than in the furosemide group. Because the annual acquisition cost of torasemide was $US518 per patient higher than that of furosemide, the resulting net cost saving per patient was $US536 for CHF and $US1027 for all cardiovascular causes. Outpatient costs did not differ between treatment groups regardless of whether drug costs were considered. Total direct costs were $US2124 lower with torasemide than with furosemide (not statistically significant). CONCLUSIONS: Owing largely to reduced readmission to the hospital, the cost of inpatient care for patients with CHF is significantly lower with torasemide than with furosemide, despite the higher acquisition cost of torasemide. Treatment with torasemide resulted in a nonsignificant reduction in total direct costs (outpatient plus inpatient) compared with furosemide.     

Comparative analysis of drug distribution costs for controlled versus noncontrolled oral analgesics

Total costs for controlled substance oral analgesics and non-controlled analgesics were compared for patients at a 548-bed university hospital. During 1983, all cost elements involved in drug delivery (excluding large-volume parenterals) were identified. Direct and indirect pharmacy labor costs were determined. Personnel costs were calculated from time studies of nurses (in 1979-80) and pharmacy technicians (in 1982). Other pharmacy costs, based on the hospital's 1982 data, included inventory holding costs, computer services, supplies, and drug acquisition costs. Costs were calculated for four oral analgesics--acetaminophen with codeine, aspirin with codeine, ibuprofen, and zomepirac sodium--used during a 30-day period in 1981. For all medications, total average cost per dose for 1,949,418 doses was $2.44, of which 41% was drug acquisition cost. Personnel costs for pharmacy and nursing accounted for 43% and 11%, respectively, of total costs. For 46% of 5111 oral analgesic doses, frequency of administration was at least four times daily. Average purchase cost per dose for the oral analgesics was $0.15, while total costs for the controlled and non-controlled drugs were $1.02 and $0.50, respectively. For the four oral analgesics in this study, cost was affected by dosage schedule and controlled or noncontrolled status. Calculation of the total average cost per dose is useful in projecting annual costs and in identifying areas for cost reduction.     

Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation

Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients.     

Medicare coverage of hospice care

Recently enacted regulations regarding Medicare coverage of hospice care are discussed. The hospice benefit, whether provided in a home or inpatient setting, is available to individuals entitled to Medicare Part A benefits and who are certified as being terminally ill. Hospice care coverage is authorized for a maximum of six months plus 30 days. Conditions of participation of the final regulations require that critical services (nursing services, physician services, and drugs and biologicals) be available on a 24-hour basis. Also, freestanding hospices must employ or contract a licensed pharmacist for control and accountability of all drugs throughout the facility. Reimbursement rates are mandated as all-inclusive, per diem rates that favor home care and have a per capita limit of $6500. The hospice benefit is a distinctly new choice of care for terminally ill patients. It also provides pharmacists an opportunity to participate in a unique aspect of health care.     

Prescribing practice and cost of antibacterial prophylaxis for surgery at a US Veteran Affairs hospital

This study retrospectively compared the actual drug-related cost of antibacterial prophylaxis for specific operative procedures with the theoretical costs based on recommendations published in Medical Letter on Drugs and Therapeutics, the Surgical Infection Society, and those of the chiefs of each surgical subspecialty at our institution. We identified all patients who received in intravenous bacterial for prophylaxis before a clean or clean-contaminated operation between 1st January and 30th September 1993, using the medical centre's computerised information system. The information included comprehensive surgical case histories, and pharmacy and microbiology records. Only those operations in which recommendations for surgical prophylaxis were present in all 3 guidelines were included. The outcome measures were antibacterial-related costs (drug acquisition and administration costs), the number of antibacterial doses dispensed, and choice of antibacterial agents. During the study period, 3,322 operations were performed, 2,993 of which were excluded. Thus, 329 patients undergoing operations in 6 subspecialties were included in the analysis. The actual mean cost per patient significantly exceeded the projected costs using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties [mean excess cost per patient: $US49.04 and $US34.95, respectively (1994 values)] and institutional guidelines for 4 of the 6 subspecialties (mean excess cost per patient: $US24.36). The actual mean number of doses per patient significantly exceeded those projected using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties (mean excess number of doses per patient: 6.0 and 4.0, respectively) and institutional guidelines for 4 of the 6 subspecialties (mean excess number of doses per patient: 2.9). The choice of antibacterial was appropriate in approximately 90% of cases. We conclude that the practice of antibacterial prophylaxis for specific operative procedures performed by 6 subspecialties is not in accordance with institutional or published guidelines, and the excess cost is primarily a result of prolonged duration of antibacterial prophylaxis.     

Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland: a cross-sectional study

BACKGROUND AND OBJECTIVE: Multiple drug use is common among old, frail nursing home residents who are, as a consequence, susceptible to adverse effects and drug interactions. This study uses the updated Beers criteria for potentially inappropriate drug (PID) use in older adults to determine the extent and nature of PIDs in older nursing home residents in Helsinki, Finland. The study also uses the Swedish, Finnish, INteraction X-referencing (SFINX) interaction database to assess the possibility of clinically significant class D ("clinically significant interaction, and the combination should be avoided") drug-drug interactions (DDIs) in the same population. METHODS: This study is a cross-sectional assessment of all nursing home residents aged > or = 65 years in Helsinki. The residents' demographic information and medical data were collected from medical charts in February 2003. RESULTS: Of all nursing home residents in Helsinki, 82% (n = 1987) were eligible for analysis. Their mean age was 83.7 (SD 7.7) years, 80.7% were female and 69.5% were diagnosed with dementia. The mean number of drugs given on a regular basis per resident was 7.9 (SD 3.6) per day. Of the study population, 34.9% regularly used at least one PID. Residents taking PIDs were more likely to be taking psychotropic medication and to be taking nine or more drugs daily, and less likely to have a diagnosis of dementia, than patients not taking PIDs. The three most prevalent PIDs were: (i) short-acting benzodiazepines in greater than recommended doses (13.9% of all residents), of which temazepam >15 mg/day was the most commonly used agent and, indeed, the most common PID (taken by 13.5% of all residents); (ii) hydroxyzine (7.1%); and (iii) nitrofurantoin (6.3%). Together, these three PIDs accounted for 76.9% of all PID use. Of all residents, 4.8% were susceptible to a clinically significant DDI. The most common potential DDIs were related to the use of potassium-sparing diuretics, carbamazepine and codeine. Compared with residents not exposed to potential DDIs, residents exposed to potential DDIs were more likely to be younger, to have a prior history of stroke, to be taking psychotropics, to be taking nine or more drugs daily and to be taking PIDs. CONCLUSION: Use of PIDs is very common among nursing home residents, and this increases the likelihood of DDIs. Monitoring patients for PID use and potential drug interactions could increase the quality of prescribing.     

Cost effectiveness of beractant in the prevention of respiratory distress syndrome

Beractant, a modified natural bovine surfactant extract, has been used successfully in the prevention of respiratory distress syndrome (RDS) in premature neonates. This analysis investigates the cost effectiveness of prophylactic surfactant therapy. Resource utilisation data were analysed retrospectively from 210 patients who had participated previously in a double-blind, placebo-controlled clinical trial. No baseline differences were apparent between the beractant and sham-air control groups. There was a significant difference in survival favouring the beractant-treated neonates. When the acquisition cost of the study drug was excluded, there was an incremental, daily cost-savings benefit for the beractant-treated group compared with the sham-air treated group. Costs per case per day were significantly lower for neonates treated with beractant ($US1442 beractant vs $US1544 sham-air; 1991 dollars p = 0.01). Costs for radiological and diagnostic procedures, respiratory care and drugs (excluding beractant) were all significantly lower. When the acquisition cost of beractant was included, the cost to produce a 28-day survivor was $US3319 less with beractant ($US41 020) than with sham-air ($US44 339). Thus, when viewed in terms of costs per year of life saved, beractant compares very favourably with other recently evaluated health technologies.