PMD4 Outcomes Research Interests of a Community Pharmacist Research Network

OBJECTIVE: This purpose of this project was to document the outcomes research interests of members of a statewide Community Pharmacist Research Network (CPR-Net).
METHODS: Pharmacists electing to participate in the CPR-Net completed a survey in which they were asked to rank on a scale of 1 to 5 (1 = low interest, 5 = high interest) their interest in conducting outcomes-related research projects (Pharmacy Care, Health Related Quality of Life, Pharmacoeconomics, and Product Evaluation) in 21 disease states. These projects would be conducted in their pharmacies in conjunction with four faculty members from a college of pharmacy.
RESULTS: CPR-Net members ranked diabetes mellitus and hypertension as the most common disorders (93.8% each) in which they would be interested in conducting research projects. Other diseases in which a high interest level was demonstrated include asthma (85.4%), hypercholesterolemia (83.3%), and arthritis (81.2%). An intermediate level of interest was demonstrated with COPD (77%), allergic rhinitis (77%), child health issues (77%), and peptic ulcer disease (72.9%). Diseases in which a low interest level was expressed include AIDS/HIV (18.8%), epilepsy (12.5%), and thyroid disorders (12.5%). Additionally, 10.4% of pharmacists expressed low interest levels in conducting studies in patients with arrhythmias, congestive heart failure, depression, and anxiety.
CONCLUSION: Community pharmacists in this research network are most interested in conducting outcomes-related research projects in patients with common, expensive, chronic diseases.     

PGD3 Cost-Utility Relation of the Treatment of Diabetic Foot Lesion with Hyperbaric Oxygene Therapy Versus Standard Therapy

Since patient adherence is related to dosage schedules and the number of medications prescribed, we questioned the relative adherence to and the economic impact of CoRx-D&M dispensed as separate agents versus ensured patient adherence with STF-D/M.
OBJECTIVE: Evaluate the economic implications of changes in patient adherence.
METHODS: Data were extracted from a Canadian, timeseries database of patient-level pharmacy claims (15.8 million pharmacy claims, totaling C$459.3 million per year). From 1/1/93 to 8/31/97, 4,880 CoRx-D&M patients were identified and 1,001 STF-D/M patients were identified. Over a 56-month period, consecutive claims were analyzed to determine relative adherence to each regimen. The adherence results were entered into a decision analysis model to project economic outcomes.
RESULTS: Adherence gradually declined in the CoRx-D&M group to 58% by the fifth diclofenac claim producing a weighted average adherence rate of 61%. Therefore, 39% of patients received NSAIDs without misoprostol. This contrasts with the 100% ensured adherence rate with STF-D/M. Using standard rates of ulcer complications for high-risk patients, the economic implications of the decline in adherence results in an increase in health care costs from $182.14 per patient per month (PPPM) (assuming 100% adherence) to $191.45 PPPM (assuming 61% adherence)-an incremental increase of $9.01 PPPM. If patients receiving co-therapy had been receiving STF-D/M, healthcare costs would be reduced from $191.45 PPPM to $188.86 PPPM-an incremental savings of $2.59 PPPM.
CONCLUSION: Removing the issue of patient nonadherence that is seen with co-prescribed medications by prescribing STF-D/M reduces the risk of NSAID-induced GI complications and decreases overall health care costs.     

DM3 Outcomes Research in Medication use: Hcfa''s Health Care Quality Improvement Program

The objective of public policy decision making is to choose the set of interventions that maximize the net benefit to society. Given a set of mutually exclusive interventions, the one with the lowest cost-effectiveness ratio is not necessarily the one that maximizes net benefit. Thus, a treatment with a higher cost-effectiveness ratio compared to baseline may result in higher net benefits if its incremental cost-effectiveness is less than the dollar value of the outcome. In this presentation we describe how to use cost-effectiveness results to determine the intervention that maximizes net benefit. We also show how cost-effectiveness results can be used to determine threshold values for the benefit than another. We then examine the effect of budget constraints on this decision making problem. We also present a graphical means of representing cost-effectiveness results that allow for easy interpretation and use of the results. We describe a simple rule for identifying the net benefit maximizing intervention from this graph. We will illustrate the issue discussed using examples from the medical literature. This workshop should be beneficial to health care decision makers who have to interpret cost-effectiveness results and incorporate them in their decision making process.     

PGD12 Cost of Prescription Drugs and Cost of Treatment Failure for Sinusitis

A self-administered, disease-specific form of health status instrument for patients with COPD is not available in America. The St. George's Respiratory Questionnaire (SGRQ) is a successful measure in Great Britain and Europe that meets these requirements, but syntax and colloquial differences make an American version necessary.
OBJECTIVE: To test the validity and reliability of an American translation (ATSGRQ) of the SGRQ.
METHODS: Two bilingual health professionals independently translated the SGRQ based on summarized input from panels of American COPD patients and American respiratory professionals. Consensus was reached on the translated version and then back-translated by two other bilingual health professionals. To establish reliability, the ATSGRQ was given to COPD patients at the beginning of a pulmonary rehabilitation program (PRP) and repeated 1 week later. To establish validity, the ATSGRQ was used with pulmonary function tests, the Medical Research Council's dyspnea scale (DYS), 6-minute walk (6MW), and Short Form Health Status Profile-36 (SF-36) at the beginning and end of PRP for 24 COPD patients.
RESULTS: The patients were mean age 70 yr, 40% male, mean FEV1 = 0.95. The ATSGRQ Cronbach's alpha for overall scale and symptom, activity, and impact components was respectively .87, .65, .79, .80. Test-retest correlations were .70, .60, .72, .64, respectively. Baseline correlations between total ATSGRQ and FEV1, DYS, 6MW, and SF-36 physical and mental health component scores were −.43, 54, .56, −.76, −.62. From initial to post-PRP, the symptom ATSGRQ decreased 12.6% (p = .004); DYS decreased 10.6% (p = .043).
CONCLUSION: Based on these preliminary data, the ATSGRQ appears to be a valid, reliable health status instrument for use in an American COPD population.     

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.     

PGD13 Does the Duration of Pulmonary Rehabilitation Affect the Magnitude of Patient Response?

OBJECTIVE: To determine if there is a dosage effect associated with the length of pulmonary rehabilitation (PR).
METHODS: We used a battery of outcome measures to quantify the amount of change that was achieved from baseline to discharge in 286 patients completing a PR program in 1 of 12 institutions participating in PROAS. The programs were of varying durations. Paired t-tests indicated overall that while the pulmonary rehabilitation programs did not yield improvements in physiologic (FEV1, FVC, % predicted FEV1) outcomes, the patients did achieve significant improvements in symptomatic (Borg score), functional (6-minute walk), general healthrelated quality of life [SF-36 Health Survey (SF-36)], and disease-specific HRQL [Chronic Respiratory Disease Questionnaire (CRQ) variables.
RESULTS: Based on a series of stepwise multiple regressions using the amount of change in each outcome variable as the dependent variable and adjusting for the corresponding baseline value and 11 clinical and sociodemographic characteristics, the number of hours of education (HREDU, 13.5 hr ± 6.7), activities of daily living (HRADL, 2.2 hr ± 6.6), and psychosocial support (6.5 hr ± 5.6) both individually and collectively (42.4 hr ± 11.8) generally did not contribute to explaining the magnitude of change achieved by the patients. However, the number of hours of supervised exercise (HREX, 25.4 hr ± 9.2) did contribute to explaining increases in 5 of the 8 SF-36 domains: physical function (p = 0.027), physical role (p = 0.0002), health perceptions (p = 0.0167), vitality (p = 0.034), and social function (p = 0.0035).
CONCLUSION: These data suggest that outcomes specifically related to pulmonary diseases are not affected by a longer duration for this type of intervention, but that broader, population-based assessments may need an additional period of intervention, or elapsed time, to detect improvement.     

无锡市健康儿童和哮喘儿童睡眠障碍发生状况比较

目的了解无锡市3~12岁健康儿童和哮喘儿童睡眠呼吸障碍常见症状的发生率,比较哮喘儿童与健康儿童之间的差异。方法抽取无锡市3个区3~12岁健康儿童2354名和无锡市儿童医院哮喘门诊的3~12岁缓解期哮喘儿童300例,分别对其家长进行儿童睡眠状况问卷调查。结果哮喘儿童睡眠障碍症状发生率为48.3%,其中睡眠频繁鼾症发生率为13.0%,喉头哽咽1.4%,张口呼吸10.1%,睡眠呼吸暂停1.6%,磨牙0.6%,梦呓1.0%,梦游0.5%,睡眠中肢体抽动1.3%,睡眠不安18.1%。哮喘儿童睡眠障碍发生率较无呼吸道疾病的正常儿童高,其中睡眠频繁打鼾、睡眠不安、张口呼吸和睡眠呼吸暂停的发生率差异存在统计学意义。结论哮喘儿童的睡眠障碍发生率高于无呼吸道疾病的正常儿童。     

精细化综合护理在氧气驱动雾化吸入辅助治疗小儿喘憋性肺炎中的应用

目的 分析精细化综合护理在氧气驱动雾化吸入辅助治疗小儿喘憋性肺炎中的临床应用价值.方法 选择我院2018年7月至2020年1月接受氧气驱动雾化吸入辅助治疗的喘憋性肺炎患儿55例,根据入院时间顺序分为两组.对照组采用常规护理,观察组采用精细化综合护理,比较两组的症状改善时间、血气指标及不良反应情况.结果 观察组气喘、咳嗽...     

CC6 Development of Asthma-Specific Outcomes Measures for Children

To facilitate the evaluation of a new pediatric asthma management program, HUFF and PUFFSM The Children's Asthma Program, a set of children's outcomes surveys, including measures of quality of life (QoL) and self-efficacy, were prepared. Each instrument was pretested through individual cognitive interviews with asthmatic children ranging in age from four to eight years old.
QUESTIONNAIRE 1: The QoL measure, the Childhood asthma Questionnaire–Form A, was developed in England by Davina French and colleagues. Although it was designed to measure both global and asthma-specific QoL in young children, the questionnaire needed to be adapted for use in the U.S. The most interesting cognitive findings pertain to children's ability to select appropriate responses and relate to item content. For example, the youngest children had difficulty distinguishing between certain response categories, and some items were not optimally worded for older children.
QUESTIONNAIRE 2: The original version of the self-efficacy measure was developed by Thomas Creer for use with adults. Because this program is targeted for young children, we initially modified the scale by reducing the number of items and adding graphics to clarify the response categories. Cognitive findings indicated that children had difficulty answering items about situations that did not trigger their asthma. Therefore, the survey was limited to triggers most commonly acknowledged by children. Gate questions were also added to ensure that children would only be asked to provide self-confidence evaluations about their personal triggers. Additional modifications were aimed at making the questions and response categories as concrete as possible.
PSYCHOMETRIC EVALUATION: Psychometric properties of these instruments will be evaluated during the pilot program which is currently under way.     

PGD8 Comparison of Prevalence Rates of Low Back Disorders Obtained from Two Large National Claims Databases

Large national claims databases are sources of vital information concerning health care resource utilization. However, the comparability of data obtained from such databases has not yet been ascertained.
OBJECTIVE: To compare prevalence rates of low back disorders obtained from two large national inpatient claims databases and to study variations in length of stay and corresponding costs.
METHODS: Data were obtained from two independent databases with inpatient claims information including ICD-9 codes for specific diagnoses, demographics, length of stay (LOS), and payments or charges made. One of the databases is a 20% national inpatient sample of all community hospitals in the U.S. (HCUP). The other national database consists of data gathered for privately insured population (MarketScan). Claims for specific diagnoses of low back disorders (ICD-9 codes: 720.0–724.9) for 1994 were obtained. Using age, gender, and diagnosis-adjusted rates (direct method), the overall low back disorder rates were compared. Also age, gender, and diagnosis-specific low back disorder rates were compared between two databases.
RESULTS: The overall adjusted prevalence rates of low back disorders were 1.49 and 1.88 per 100 admissions for HCUP and MarketScan, respectively. Significant difference was observed in the age, gender-adjusted rates for diagnosis of displacement of lumbar intervertebral disc without myelopathy, with MarketScan showing a higher rate as compared to HCUP (1.06 vs. 0.78/100 admissions). The adjusted average LOS and age, gender, and diagnosis-specific LOS were higher for HCUP than MarketScan. The specific and adjusted payments (based on MarketScan) were, however, higher than the charges reported in HCUP.
CONCLUSIONS: The prevalence rate of low back disorders is higher in the MarketScan database than in HCUP. The differences in the length of stay and associated costs might be attributable to other variables such as geographical variations.     

PGD5 Predicting Hospitalization of Patients with Diabetes Mellitus: An Application of the Bayesian Discriminant Analysis

An estimated 8 million people in the U.S. have type II diabetes mellitus but are unaware of it.
OBJECTIVES: The study investigated the cost-effectiveness of early detection of type II diabetes mellitus in various risk groups.
METHODS: A Markov model was constructed based on a societal perspective. There were 4 stages in the model: (1) unknown diabetes status; (2) alive with diagnosed diabetes; (3) alive with diagnosed diabetes and related complications, namely, retinopathy, blindness, neuropathy, end-state renal disease, lower leg amputations, circulatiory disorders; and (4) die secondary to diabetes or its complications. Individuals could transit from one state to another annually as a function of the predicted risk factors from epidemiological studies. The model assumed that the patients who were screened positive for diabetes and received treatment would have reduced rate of related complications as observed in the Diabetes Control and Complications Trial. Health care costs included in the model were screening tests, diabetes treatment cost, complications and death. Various screening test thresholds have also been considered in the model analysis.
RESULTS: Diabetes screening of the entire nonpregnant adult US population yielded a cost-effectiveness ratio of $24,600 per quality-adjusted life year. The cost-effectiveness of screening only extremely obese patients with a family history of diabetes was $10,083 per quality adjusted life year.
CONCLUSIONS: The study suggested that active screening for type II diabetes mellitus in high-risk individuals was cost-effective. More information on the actual clinical outcomes for oral diabetes medications is needed to establish the precision of these estimates.     

PHB8 Cost-Effectiveness of Hormone Therapy Versus Calcium Therapy: An Osteoporosis Markov Model

Osteoporosis is a chronic degenerative disease with concentrated prevalence in the most rapidly growing segment of the population, the elderly. Its clinical and economic consequences are substantial. This study assesses the cost-effectiveness of two gold standard therapeutic approaches to reducing the impact of related fractures.
OBJECTIVES: To determine the cost-effectiveness ratios of the two therapeutic approaches. To model the cohort progression through the Markov states.
METHODS: Using published literature values, a Markov model was constructed. The model depicts a cohort of 1,000 women progressing from age 50 to 90 years or death, whichever comes first. The hormone therapy alternative includes calcium supplementation as part of the regimen. The model accounts for the following confounders: age dependent rate of death, predisposition to subsequent fracture, and the cardioprotective effect of hormone therapy. Sensitivity analysis was conducted on all relevant variables to assess the robustness of the findings. The primary outcome of interest was cost per fracture avoided. Additionally, Markov analysis of the model reports the distribution of women across each Markov state.
RESULTS: The study revealed that hormone therapy is more cost-effective than calcium therapy. Cost-effectiveness ratios for the two alternatives were $43,729.82 and $87,003.53 per fracture avoided for hormone therapy and calcium therapy, respectively. The incremental cost-effectiveness ratio was $32,828.60, indicating the cost of avoiding each additional fracture using the less desirable calcium therapy. The cardioprotective effect of hormone therapy accounted for nearly 3 additional years of life for each woman on therapy.
CONCLUSIONS: Hormone replacement therapy in conjunction with calcium supplementation is far more cost-effective than calcium supplementation alone.     

哮喘儿童淋巴细胞CD19的表达

哮喘是一种气道慢性变态反应性炎症性疾病 ,许多细胞、细胞因子和炎性介质参与了这种炎症反应 ,免疫功能失调在支气管哮喘发病机理中起着重要作用。本研究运用流式细胞仪分析技术检测哮喘儿童外周血淋巴细胞CD1 9的阳性率 ,以探讨CD1 9与儿童哮喘之间的关系。对象与方法1　对象　根据 1998年全国儿科哮喘防治协作组修订的儿童哮喘诊断标准及哮喘的分期与病情评价标准。哮喘发作组 30例 ,其中轻度 18例 ,中重度 12例 ;男 18例 ,女 12例 ;年龄 3～ 13岁 ,平均 6 30± 2 71岁。喘哮缓解组 30例 ,病情缓解时间均超过 4周 ;男 14例 ,女 16例 …     

PMD9 Evaluation of a Pathway for Providing Pharmaceutical Care

This study is the first to examine the determination of birth outcomes, employing individual data at the national level in the U.S. The data source is from the 1987 U.S. linked birth/infant death certificates. Our analytical framework is to estimate the infant health production function from a behavioral model in which health inputs are themselves choices. We place major emphasis on the instrumental variables method of estimation to correct for the endogeneity bias. The effects of endogenous inputs, such as prenatal care, maternal age, and fertility, on birth weight are investigated. We specially focus on the analysis of the effect of prenatal care on birth weight, controlling for endogeneity of prenatal care, maternal age, and fertility.
We find that OLS underestimates the gains to prenatal care by a factor of 9.4 for blacks, about 3.1 for whites, and 4.8 for the pooled blacks and whites sample. Black mothers who seek prenatal care one month earlier give birth to babies 124 g more in birth weight, while for white mothers the corresponding number is about 99 g. The policy implications for this study are straightforward. The benefits for public prenatal care programs appear substantial, especially for blacks. Moreover, costeffective approaches to improving birth outcomes through the expanded utilization of prenatal care will motivate women who otherwise would receive late or no care to begin care in the early trimester.     

PCV5 Pharmaceutical Costs of Patient Non-Adherence to Lipid-Lowering Drug Therapy

The "statin" market is highly competitive, with primary differences being lipid-lowering ability and acquisition cost. Health care decision makers must be able to demonstrate and compare the clinical and economic value of each statin. To date, the best available data for such comparisons come from the long-term studies 4S, CARE, and WOSCOPS.
OBJECTIVE: Lipobay, a potent new statin, was recently introduced in Europe and will be introduced in the United States as Baycol this year. Our objective was to model the clinical and economic results of 4S to compare the cost-efficiency of Lipobay to other statins.
METHODS: Our research was based on the following assumptions: lipid-lowering ability and acquisition cost are the only distinctions among statins; a positive linear relationship exists between reduced lipids and reduced cardiovascular costs; all statins, based on efficacy and cost, can be incorporated into this relationship. Using these assumptions, we extracted numeric data points for cardiac hospitalization cost in 4S and developed a linear equation, incorporating efficacy and drug cost, to estimate total cost for each statin. Our cost-efficiency measurement consisted of an index calculated by dividing estimated annual per patient total cost or drug cost in Deutchmarks by unit reduction in LDL. This measurement is interpreted as the cost per unit reduction in LDL. Drugs whose total and drug cost indices had negative or zero slopes when graphed and low indices were considered cost-efficient.
RESULTS: Lipobay presented a negative slope for the total cost indices and a zero slope for drug cost indices. When comparing actual cost indices for all drugs, Lipobay was generally within mid-range (total cost: DM98–DM149; drug cost: DM14).
CONCLUSION: Lipobay is cost-efficient when compared to other statins, particularly when considering drug cost and efficacy.