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51.
Statutory reimbursement agencies as well as private insurers throughout member states of the Organization for Economic Cooperation and Development (OECD) reimburse the cost of medicines on the basis of criteria that include robust clinical evidence, budget impact analysis, and incremental cost effectiveness. The Centers for Medicare and Medicaid Services (CMS) in the US are no exception to this rule and are, in principle, seeking to maximize benefit for their Medicare enrollees, whilst ensuring reasonable drug outlays for the small number of drugs that they reimburse. This paper provides a retrospective analysis of the way two functionally equivalent drugs are treated for reimbursement purposes by the CMS; the period under consideration was 2001–3. The two drugs, epoetin-α and darbepoetin-α, are used for the treatment of anemia in renal failure and in patients receiving chemotherapy. By reviewing the publicly available pharmacological and clinical data of epoetin-α and darbepoetin-α, the paper confirms the two drugs’ functional equivalence, despite their structural differences. The implications of dose conversion ratios and costs to Medicare are subsequently explored. It is argued that the issue of dose equivalence between epoetin-α and darbepoetin-α has significant implications for patients, practitioners, and payors. A payor’s perspective is adopted in this respect, whereby clinical evidence and pricing data are used simultaneously. Based on the clinical evidence, a dose conversion ratio for epoetin-α:darbepoetin-α is established, which achieves a comparable clinical effect for the two drugs and this is set to be <254IU:1μg. The incremental costs to Medicare are calculated subsequently. The Average Wholesale Price and the Outpatient Prospective Payment System rule that Medicare uses to reimburse providers are used and suggest that treatment of cancer patients with chemotherapy-related anemia with epoetin-α would save Medicare an estimated $US600 million each year. Patients would also benefit significantly in terms of lower co-payments for epoetin-α. The evidence is supportive of the decision made by the CMS to reimburse the two drugs at the rate reflecting the achievement of comparable clinical effects and therefore reducing the pass-through payments for darbepoetin-α to zero for the 2002–3 fiscal year. 相似文献
52.
A Ahmad 《The British journal of surgery》1986,73(11):917-919
Assessment of completeness of vagotomy has always been an irksome and time-consuming affair. The commonly employed test of insulin-induced hypoglycaemia (Hollander) is tedious, risky and associated with practical limitations and theoretical objections, which have resulted in its being replaced by the modified sham feed technique in some centres. The postprandial alkaline tide is attributed to HCO3- release consequent to H+ secretion. Any procedure which reduces acid secretion is expected to affect the postprandial urinary pH. This study was performed to evaluate the effect of vagotomy on the postprandial alkaline tide by measuring prevagotomy and postvagotomy fasting and postprandial urinary pH. The results show that postprandial urinary pH falls after vagotomy and this method may be used to assess the completeness of vagotomy. The proposed test is convenient and may be used as a screening method in the assessment of vagotomy and other acid reducing operative procedures, if further validated, by comparison with already established tests. 相似文献
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Chad G. Ball Andrew W. Kirkpatrick Matthew Smith Robert H. Mulloy Leonard Tse Ian B. Anderson 《European journal of trauma and emergency surgery》2007,33(5):550-552
Abstract We report a case of SMV injury in a critically ill patient. The patient was a 19-year-old woman involved in a motor vehicle
collision. Her injuries included grade II splenic and renal lacerations, devascularized and lacerated right and transverse
colon, a transected transverse mesocolon, a massive shear injury of her abdominal wall, and two partial SMV transections.
At initial damage control laparotomy, the SMV was ligated, the devascularized bowel resected and a temporary abdominal closure
applied. At re-operation, a mesocaval shunt using saphenous vein was employed. The shunt failed and the patient required a
saphenous vein jump graft. Although visceral vascular injuries are rare, ligation of the SMV in a damage control situation
is acceptable. This case study is the first to discuss appropriate treatment when interruption to a patient's collateral visceral
venous drainage limits the surgeon’s ability to ligate. In these situations, bypass shunts may be successful. 相似文献
57.
Henry Cisneros 《AIDS and behavior》2007,11(2):7-8
For persons battling HIV/AIDS a stable place to live may decide the length and quality of life itself. It is nearly impossible for a person on the streets to engage in a needed continuous AIDS treatment regimen when the very basic question of where that person will rest his or her head when darkness comes in just a few hours is unresolved. When danger lurks on the streets, when cold numbs the limbs, when tiredness overwhelms the mind, when fear breaks the spirit, a place to call home would make all the difference. 相似文献
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Christian Waydhas Dieter Nast-Kolb Steffen Ruchholtz 《European journal of trauma and emergency surgery》2007,33(2):170-175
Abstract
Objective: To define the diagnostic accuracy of clinical examination in patients with impaired consciousness or endotracheal intubation
to detect pelvic ring fractures and to identify those with severe bleeding.
Methods: Included in this prospective data collection with retrolective data analysis were a consecutive series of blunt trauma victims
with either a Glasgow Coma Scale ≤ 13 or tracheal intubation. Clinical examination comprised testing for stability of the
iliac wings.
Results: From 784 subjects (injury severity score 23.3 ± 17.4) 93 patients (11.9%) were found to have a pelvic ring fracture. Clinical
instability of the pelvic ring was found in 42 patients. There was only one false positive. Fifty-two fractures could not
be identified by clinical examination, including nine fractures (17%) that required surgical fracture stabilization (sensitivity
of clinical examination 44.1%). Seventeen fractures (18.3%) were associated with a blood loss larger than 20% of circulating
blood volume. Sixteen of those were identified by clinical instability of the pelvic ring (sensitivity 94.1%, specificity
97.0%, positive predictive value 38.1%, negative predictive value 99.9%).
Conclusions: Clinical examination for stability of the pelvis in this selected group of patients missed a significant number of pelvic
ring fractures including fractures that require surgical stabilization. The finding of a clinically unstable identifies most
of the patients with the pelvic ring fracture being a major source of bleeding. A stable pelvis makes pelvic ring fracture
as being the source of bleeding quite unlikely. 相似文献
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