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Dawes J. Should patients be self-testing their INR? Br J Community Nurs 2008; 13:249. [PMID: 18773756 DOI: 10.12968/bjcn.2008.13.6.29455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The trend in people living longer and healthier lives is not about to change, current government policy reflects this. The Conservative party is looking increasingly likely to get a foothold on a delicate NHS. Never since the beginning of the NHS has there been a more urgent time to save money. The limited pot from which we all draw is providing more services to a growing population.
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Torstensson I, Bäck SE. [Questionnaires at anticoagulation clinics in the Southern health care region. A national quality registry is needed]. LAKARTIDNINGEN 2008; 105:1284-1288. [PMID: 18561530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Jowett S, Bryan S, Mahé I, Brieger D, Carlsson J, Kartman B, Nevinson M. A multinational investigation of time and traveling costs in attending anticoagulation clinics. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:207-212. [PMID: 18380632 DOI: 10.1111/j.1524-4733.2007.00253.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Anticoagulation is used in patients with atrial fibrillation to reduce the risk of ischemic stroke. The therapy requires regular monitoring and, frequently, dose adjustment. This study aimed to determine the time and traveling costs that patients incur to themselves and society in attending anticoagulation clinics. METHODS A subset of patients from 105 primary and secondary care clinics allocated to the warfarin arm of SPORTIF III (patients from Australia, France, Portugal, Spain, Sweden, and the UK) completed a questionnaire. Patients indicated the type of transport used for clinic visits, and estimated traveling expenses. Patients were also asked to estimate total traveling and clinic attendance time, and to confirm whether they were currently employed and whether they had to give up time from work to attend the clinic. Time cost of companions was also taken into consideration. Cost per visit was calculated (euro, 2003 prices). RESULTS Questionnaires for a total of 381 patients were analyzed, with the majority of patients from Sweden (n = 130) and the UK (n = 101). Mean cost to patients varied widely between countries, ranging from euro6.9 (France) to euro20.5 (Portugal) per visit. For most countries, time costs (value of lost working and leisure time) were the main driver of costs. Mean time cost to society ranged from euro5.6 (France) to euro31.7 (Portugal) per visit. CONCLUSIONS Patients incur considerable costs when visiting anticoagulation clinics, and these costs vary by country. The results suggest the importance of taking a broad economic perspective when considering the cost-effectiveness of warfarin.
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Strandberg K. [Non-interventional studies give good follow-up possibilities. Increased demand both nationally and internationally can be predicted]. LAKARTIDNINGEN 2007; 104:2597-2599. [PMID: 17970395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Brandt C, Baumann P, Eckermann G, Hiemke C, May TW, Rambeck B, Pohlmann-Eden B. „Therapeutic drug monitoring“ in Epileptologie und Psychiatrie. DER NERVENARZT 2007; 79:167-74. [PMID: 17701390 DOI: 10.1007/s00115-007-2325-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Experts from epileptology and psychiatry reviewed the current significance of therapeutic drug monitoring (TDM) of antiepileptic drugs and psychiatric drugs in a workshop at Bethel Epilepsy Centre in December 2005. TDM has been essential in epileptology for about 30 years, and it is also increasingly important in psychiatry, in which consensus recommendations were published recently. With regard to cost-cutting in the health system, there are discussions about the financial effect of TDM and outsourcing it to bigger laboratories. In psychiatry it has however been shown that sensibly used TDM may lead to reduced costs. Many issues in TDM require the knowledge and experience of specialised laboratories. The use of TDM data for scientific purposes was discussed at the workshop as well.
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Cressey TR, Nangola S, Tawon Y, Pattarawarapan M, Lallemant M, Tayapiwatana C. Immunochromatographic strip test for rapid detection of nevirapine in plasma samples from human immunodeficiency virus-infected patients. Antimicrob Agents Chemother 2007; 51:3361-3. [PMID: 17606683 PMCID: PMC2043209 DOI: 10.1128/aac.00445-07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report a novel one-step immunochromatographic strip test for the rapid, qualitative detection of nevirapine in plasma samples from human immunodeficiency virus-infected patients. The sensitivity was 100% (95% confidence interval [95% CI], 97.8 to 100%), and the specificity was 99.5% (95% CI, 97.2 to 99.9%). The limit of detection was 25 ng/ml. Immunochromatographic strip tests are simple, rapid, and cheap assays that could greatly facilitate drug level monitoring in resource-limited settings.
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Cunha BA, Mohan SS, Hamid N, McDermott BP, Daniels P. Cost-ineffectiveness of serum vancomycin levels. Eur J Clin Microbiol Infect Dis 2007; 26:509-11. [PMID: 17534676 DOI: 10.1007/s10096-007-0314-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Natarajan G, Botica ML, Thomas R, Aranda JV. Therapeutic drug monitoring for caffeine in preterm neonates: an unnecessary exercise? Pediatrics 2007; 119:936-40. [PMID: 17473094 DOI: 10.1542/peds.2006-2986] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to determine the value of measuring plasma caffeine levels in preterm neonates treated with caffeine for apnea. We evaluated plasma concentrations of caffeine attained in preterm neonates at standard doses, at varying postconceptual ages, with renal or hepatic dysfunction and when there was clinical lack of efficacy. We hypothesized that measurement of plasma caffeine concentrations during apnea therapy is not clinically helpful. PATIENTS/METHODS An observational study was conducted at Hutzel Women's Hospital between January 2000 and September 2005. Preterm neonates who were being treated with caffeine and who had a plasma caffeine level measured on at least 1 occasion were included. RESULTS A total of 231 caffeine blood levels were obtained from 101 preterm neonates with a median gestation of 28 weeks (range: 23-32 weeks) and birth weight of 1030 g (range: 540-2150 g). The caffeine citrate dose used ranged form 2.5 to 10.9 mg/kg (median: 5 mg/kg), and the levels ranged from 3.0 to 23.8 mg/L. Levels were between 5.1 and 20 mg/L in 94.8%, <5 mg/L in 2.1%, and >20 mg/L in 3.1%. Levels in the 5.1 to 20 mg/L range were attained on 91.3% of occasions when there was concomitant renal dysfunction (n = 23) and in all cases of hepatic dysfunction (n = 13). The median (25th, 75th quartiles) levels drawn for lack of efficacy (14.1 [10.2, 8.3] mg/L; n = 94) were comparable to those obtained for routine monitoring (13.7 [11, 9] mg/L; n = 107). CONCLUSIONS A majority of preterm neonates attain plasma caffeine levels between 5 and 20 mg/L, independent of gestation. This observation held even for the small number of subjects with elevated blood urea nitrogen, serum creatinine, or liver enzyme levels. Therapeutic drug monitoring is not necessary when caffeine is used for the treatment of apnea of prematurity in neonates.
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Björholt I, Andersson S, Nilsson GH, Krakau I. The cost of monitoring warfarin in patients with chronic atrial fibrillation in primary care in Sweden. BMC FAMILY PRACTICE 2007; 8:6. [PMID: 17324260 PMCID: PMC1820599 DOI: 10.1186/1471-2296-8-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 02/26/2007] [Indexed: 11/24/2022]
Abstract
Background Warfarin is used for the prevention of stroke in chronic atrial fibrillation. The product has a narrow therapeutic index and to obtain treatment success, patients must be maintained within a given therapeutic range (International Normalised Ratio;INR). To ensure a wise allocation of health care resources, scrutiny of costs associated with various treatments is justified. The objective of this study was to estimate the health care cost of INR controls in patients on warfarin treatment with chronic atrial fibrillation in primary care in Sweden. Methods Data from various sources were applied in the analysis. Resource consumption was derived from two observational studies based on electronic patient records and two Delphi-panel studies performed in two and three rounds, respectively. Unit costs were taken from official databases and primary health care centres. Results The mean cost of one INR control was SEK 550. The mean costs of INR controls during the first three months, the first year and during the second year of treatment were SEK 6,811, SEK 16,244 and SEK 8,904 respectively. Conclusion INR controls of patients on warfarin treatment in primary care in Sweden represent a substantial cost to the health care provider and they are particularly costly when undertaken in home care. The cost may however be off-set by the reduced incidence of stroke.
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McCahon D, Murray ET, Jowett S, Sandhar HS, Holder RL, Hussain S, O'Donoghue B, Fitzmaurice DA. Patient self management of oral anticoagulation in routine care in the UK. J Clin Pathol 2007; 60:1263-7. [PMID: 17259295 PMCID: PMC2095473 DOI: 10.1136/jcp.2006.044008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Self management of anticoagulation: a randomised trial (SMART) was the first large scale UK trial to assess clinical and cost effectiveness of patient self management (PSM) of oral anticoagulation therapy compared to routine care. SMART showed that while PSM was as clinically effective as routine care, it was not as cost effective. SMART adds to the growing body of trial data to support PSM; however there are no data on clinical effectiveness and cost of PSM in routine care. AIM To evaluate clinical effectiveness of PSM compared to routine care outside trial conditions. METHODS A retrospective multicentre matched control study. 63 PSM patients from primary care in the West Midlands were matched by age and international normalised ratio (INR) target with controls. INR results were collected for the period 1 July 2003-30 June 2004. The primary outcome measure was INR control. RESULTS 38 PSM and 40 control patients were recruited. INR percentage time in range was 70% PSM vs 64% controls. 60% PSM were having a regular clinical review, 45% were performing an internal quality control (IQC) test and 82% were performing external quality assurance (EQA) on a regular basis. CONCLUSION PSM outside trial conditions is as clinically effective as routine UK care.
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Johnson JA, Pohar SL, Secnik K, Yurgin N, Hirji Z. Utilization of diabetes medication and cost of testing supplies in Saskatchewan, 2001. BMC Health Serv Res 2006; 6:159. [PMID: 17164006 PMCID: PMC1762014 DOI: 10.1186/1472-6963-6-159] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 12/12/2006] [Indexed: 11/10/2022] Open
Abstract
The purpose of this study was to describe the patterns of antidiabetic medication use and the cost of testing supplies in Canada using information collected by Saskatchewan's Drug Plan (DP) in 2001. The diabetes cohort (n = 41,630) included individuals who met the National Diabetes Surveillance System (NDSS) case definition. An algorithm was then used to identify subjects as having type 1 or type 2 diabetes. Among those identified as having type 2 diabetes (n = 37,625), 38% did not have records for antidiabetic medication in 2001. One-third of patients with type 2 diabetes received monotherapy. Metformin, alone or in combination with other medications, was the most commonly prescribed antidiabetic medication. Just over one-half of the all patients with diabetes had a DP records for diabetes testing supplies. For individuals (n = 4,005) with type 1 diabetes, 79% had a DP record for supplies, with an average annual cost of 472 +/- 560 dollars. For type 2 diabetes, 50% had records for testing supplies, with an average annual cost of 122 +/- 233 dollars. Those individuals with type 2 diabetes who used insulin had higher testing supply costs than those on oral antidiabetic medication alone (359 vs 131 dollars; p < 0.001).
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Andersson S, Björholt I, Nilsson GH, Krakau I. Resource consumption and management associated with monitoring of warfarin treatment in primary health care in Sweden. BMC FAMILY PRACTICE 2006; 7:67. [PMID: 17096858 PMCID: PMC1654161 DOI: 10.1186/1471-2296-7-67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 11/12/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Warfarin is used for the prevention and treatment of various thromboembolic complications. It is an efficacious anticoagulant, but it has a narrow therapeutic range, and regular monitoring is required to ensure therapeutic efficacy and at the same time avoid life-threatening adverse events. The objective was to assess management and resource consumption associated with patient monitoring episodes during warfarin treatment in primary health care in Sweden. METHODS Delphi technique was used to systematically explore attitudes, demands and priorities, and to collect informed judgements related to monitoring of warfarin treatment. Two separate Delphi-panels were performed in three and two rounds, respectively, one concerning tests taken in primary health care centres, involving 34 GPs and 10 registered nurses, and one concerning tests taken in patients' homes, involving 49 district nurses. RESULTS In the primary health care panel 10 of the 34 GPs regularly collaborated with a registered nurse. Average time for one monitoring episode was estimated to 10.1 minutes for a GP and 21.4 minutes for a nurse, when a nurse assisted a doctor. The average time for monitoring was 17.6 minutes for a GP when not assisted by a nurse. Considering all the monitoring episodes, 11.6% of patient blood samples were taken in the individual patient's home. Average time for such a monitoring episode was estimated to 88.2 minutes. Of all the visits, 8.2% were performed in vain and took on average 44.6 minutes. In both studies, approximately 20 different elements of work concerning management of patients during warfarin treatment were identified. CONCLUSION Monitoring of patients during treatment with warfarin in primary health care in Sweden involves many elements of work, and demands large resources, especially when tests are taken in the patient's home.
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Rezk NL, Crutchley RD, Yeh RF, Kashuba ADM. Full validation of an analytical method for the HIV-protease inhibitor atazanavir in combination with 8 other antiretroviral agents and its applicability to therapeutic drug monitoring. Ther Drug Monit 2006; 28:517-25. [PMID: 16885719 DOI: 10.1097/00007691-200608000-00006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because HIV medications are used in combination, it is important to develop multiplex assays to streamline the therapeutic drug monitoring process and provide rapid turnaround. This article reports full validation of an analytical method that combines atazanavir with 6 HIV-protease inhibitors (indinavir, amprenavir, saquinavir, nelfinavir, ritonavir, and lopinavir) and 2 nonnucleoside reverse transcriptase inhibitors (nevirapine and efavirenz). Using 200 microL of plasma and a simple liquid-liquid extraction method, this analytical method achieved a clean baseline and high extraction efficiencies (90.0% to 99.5%). A Zorbax C-18 (150 x 4.6 mm, 3.5 microm) analytical column was used along with a 27-minute linear gradient elution of the mobile phase to provide sharp peaks at 210 nm. This method was validated over a range of 25 to 10,000 ng/mL and is accurate (90.4% to 110.5%) and precise (precision within a day and between days ranged from 2.3% to 8.3%). Because this method is simple and inexpensive, it may have applicability in countries with low resources.
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Funahashi J, Ohkubo T, Fukunaga H, Kikuya M, Takada N, Asayama K, Metoki H, Obara T, Inoue R, Hashimoto J, Totsune K, Kobayashi M, Imai Y. The economic impact of the introduction of home blood pressure measurement for the diagnosis and treatment of hypertension. Blood Press Monit 2006; 11:257-67. [PMID: 16932035 DOI: 10.1097/01.mbp.0000217996.19839.70] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the economic consequences resulting from introduction of home blood pressure measurement in diagnosis of hypertension instead of casual clinic blood pressure measurement. METHODS We constructed a decision tree model using data from the Ohasama study and a Japanese national database. The Ohasama study provided the prognostic value of home blood pressure as compared with clinic blood pressure measurement. RESULTS It is predicted that the use of home blood pressure for hypertension diagnosis results in a saving of 9.30 billion US dollars (1013.6 billion yen) in hypertension-related medical costs in Japan. Most of this was attributable to medical costs saved by avoiding the start of treatment for untreated individuals who were diagnosed as hypertensive by clinic blood pressure but whose blood pressures were in the normal range when based on home blood pressure; that is, the so called white-coat hypertension. Furthermore, it could be expected that adequate blood pressure control mediated by the change in the diagnostic method from clinic to home blood pressure measurement would improve the prognosis for hypertension. We estimated that the prevention of hypertensive complications resulted in a reduction of annual medical costs by 28 million US dollars (3.0 billion yen). In addition, stroke prevention due to adequate blood pressure control based on home blood pressure measurement reduced annual long-term care costs by 39 million US dollars (4.2 billion yen). A per-person break-even cost for introducing home blood pressure monitoring was calculated as 409 US dollars (44,580 yen). CONCLUSIONS The introduction of home blood pressure measurement for the diagnosis and treatment of hypertension would be very effective to save costs.
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Paez KA, Allen JK. Cost-effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization. ACTA ACUST UNITED AC 2006; 18:436-44. [PMID: 16958775 DOI: 10.1111/j.1745-7599.2006.00159.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of case management by a nurse practitioner (NP) to lower blood lipids in patients with coronary heart disease (CHD) from a managed care perspective. DATA SOURCES A total of 228 consecutive, eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization. Patients were randomized to receive lipid management, including individualized lifestyle modification and pharmacologic intervention from an NP for 1 year after discharge in addition to their usual care (NURS) or to receive usual care (EUC) enhanced with feedback on lipids to their primary provider and/or cardiologist. A cost-effectiveness ratio was calculated using incremental costs of the NURS group per unit change and percent change in low-density lipoprotein cholesterol (LDL-C) for 1 year at 2004 values. CONCLUSIONS The annual incremental cost-effectiveness of NP case management was 26.03 dollars per mg/dL and 39.05 dollars per percent reduction in LDL-C. When costs of NURS care for the second 6 months of management were compared to the first 6 months of management, nursing salary costs were lower as patients were established on cholesterol management regimens, but the reduction in costs was offset by the increase in incremental costs of drug treatment as the NP titrated the patient to higher drug dosages that were more costly. IMPLICATIONS FOR PRACTICE The findings suggest that case management by an NP is a cost-effective approach for a managed care organization to consider in improving the care of patients with cardiovascular disease.
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Cohn TA, Sernyak MJ. Metabolic monitoring for patients treated with antipsychotic medications. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2006; 51:492-501. [PMID: 16933586 DOI: 10.1177/070674370605100804] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Metabolic side effects of antipsychotic treatment include weight gain, dyslipidemia and increased susceptibility to diabetes. Patients with schizophrenia have increased coronary heart disease mortality and reduced life expectancy. There is an urgent clinical need to monitor antipsychotic-treated patients for metabolic disturbance. Our objectives were to review published international monitoring guidelines, establish goals for metabolic monitoring, and make recommendations for practice. METHOD We reviewed the major published consensus guidelines for metabolic monitoring of patients treated with antipsychotic medications and selectively reviewed practice guidelines for the management of diabetes, dyslipidemia, and hypertension. RESULTS Patients with serious mental illness have markedly elevated rates of metabolic disturbance and limited access to general medical care. Monitoring, but not necessarily medical treatment of metabolic disorder, falls within the scope of psychiatric practice and should include screening for metabolic disturbance as well as tracking the effects of antipsychotic treatment. In addition, psychiatrists and psychiatric services should work toward facilitating patients' access to medical care. There is considerable consensus in the published guidelines. Areas of dissent include which patients to monitor, the utility of glucose tolerance testing, and the point at which to consider switching antipsychotics. CONCLUSION We encourage clinicians to adopt a structured system for conducting and recording metabolic monitoring and to develop collaborations with family physicians, diabetes specialists, dieticians, and recreation therapists to facilitate appropriate medical care for antipsychotic-treated patients.
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Abstract
We describe the results of a novel complete care package using point-of-care INR testing and computerized decision support for the management of oral anticoagulation by nurse-led primary care clinics in the United Kingdom. We found such therapy to be as safe and effective as traditional hospital-based care for oral anticoagulation in the UK as determined by adverse events or International Normalized Ratio (INR) time in range. We then review the literature as it pertains to the safety, efficacy, and cost effectiveness of patient self-management with point-of-care INR testing at home and discuss the implications for such care in the UK.
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Portolés A, Palau E, Puerro M, Vargas E, Picazo JJ. Health economics assessment study of teicoplanin versus vancomycin in Gram-positive infections. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2006; 19:65-75. [PMID: 16688294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The objective of this study, conducted at Hospital Clínico San Carlos, Madrid, Spain, was to compare the cost of treatment of Gram-positive infections with teicoplanin and vancomycin under normal conditions. Using a prospective observational study design for drug utilization and economic assessment, we evaluated the comparability of the sample, adverse events, features of treatment with teicoplanin/vancomycin and factors influencing the consumption of resources until the end of glycopeptide treatment or discharge (whichever occurred later) using Health System perspective. Costs were assigned using the hospital's evaluation at the time of the study. Analyses made: multivariate, sensitivity (by modifying staff or acquisition costs) and simulation of reduction of stay by early discharge in the teicoplanin group. Study participants included 201 patients who had been using teicoplanin (n=100) or vancomycin (n=101) for at least four days. Data collected daily outside morning work timetable. Costs of acquisition, administration and monitoring by course of treatment (mean+/-SD, in euros) were lower in the vancomycin group (teicoplanin euro647.62+/-euro572.75 vs. vancomycin euro378.11+/-euro225.90); when total costs (including hospital stay) were considered, no differences were found (teicoplanin euro4,432.04+/-euro3,383.46 vs. vancomycin euro4,364.44+/-euro2,734.24). Conditions of use and results were similar for both antibiotics. The economic results of acquisition, administration and monitoring were advantageous for vancomycin; when global costs of care were taken into account, these differences were not evident. Tolerability was significantly advantageous in the teicoplanin group (with regard to phlebitis and elevation of creatininemia), without differences in clinical or economic outcomes. The formulation of teicoplanin did not take advantage of its potential benefits of administration.
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Beran D, Yudkin JS, de Courten M. Assessing health systems for type 1 diabetes in sub-Saharan Africa: developing a 'Rapid Assessment Protocol for Insulin Access'. BMC Health Serv Res 2006; 6:17. [PMID: 16504123 PMCID: PMC1402284 DOI: 10.1186/1472-6963-6-17] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 02/24/2006] [Indexed: 11/24/2022] Open
Abstract
Background In order to improve the health of people with Type 1 diabetes in developing countries, a clear analysis of the constraints to insulin access and diabetes care is needed. We developed a Rapid Assessment Protocol for Insulin Access, comprising a series of questionnaires as well as a protocol for the gathering of other data through site visits, discussions, and document reviews. Methods The Rapid Assessment Protocol for Insulin Access draws on the principles of Rapid Assessment Protocols which have been developed and implemented in several different areas. This protocol was adapted through a thorough literature review on diabetes, chronic condition management and medicine supply in developing countries. A visit to three countries in sub-Saharan Africa and meetings with different experts in the field of diabetes helped refine the questionnaires. Following the development of the questionnaires these were tested with various people familiar with diabetes and/or healthcare in developing countries. The Protocol was piloted in Mozambique then refined and had two further iterations in Zambia and Mali. Translations of questionnaires were made into local languages when necessary, with back translation to ensure precision. Results In each country the protocol was implemented in 3 areas – the capital city, a large urban centre and a predominantly rural area and their respective surroundings. Interviews were carried out by local teams trained on how to use the tool. Data was then collected and entered into a database for analysis. Conclusion The Rapid Assessment Protocol for Insulin Access was developed to provide a situational analysis of Type 1 diabetes, in order to make recommendations to the national Ministries of Health and Diabetes Associations. It provided valuable information on patients' access to insulin, syringes, monitoring and care. It was thus able to sketch a picture of the health care system with regards to its ability to care for people with diabetes. In all countries where this tool was used the involvement of local stakeholders resulted in the process acting as a catalyst in bringing diabetes to the attention of the health authorities.
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Albrecht R. MCOs following innovative CMS remote monitoring initiative: self-testing service is designed to lower costs and improve outcomes for anticoagulation therapy. MANAGED CARE QUARTERLY 2006; 14:13-6. [PMID: 17590971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Managing anticoagulation therapy has been difficult and costly for providers and for payers, as complications are common. For example, the cost of mitigating a single anticoagulation related hemorrhagic complication can exceed $10,000 per claim. In 2002, CMS initiated a new model of anticoagulation patient management that combines technology with remote monitoring to improve traditional care. Managed care organizations are now adopting this model, and improved outcomes at lower cost should result.
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Abstract
We analysed the pharmaco-economics of the prospective peri-operative studies of statin administration for major elective vascular surgery, using the NHS reference costs for 2004. This analysis suggests that peri-operative statin therapy for patients undergoing vascular surgery may present the most cost-effective use of statin therapy yet described, with a number-needed-to-treat of 15 and almost 60% of the total cost of atorvastatin therapy recovered through a reduction in peri-operative adverse events.
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InstaRead Lithium System. THE MEDICAL LETTER ON DRUGS AND THERAPEUTICS 2005; 47:82-3. [PMID: 16247340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
A finger-stick office test for measuring serum lithium concentrations.
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Dubinsky MC, Reyes E, Ofman J, Chiou CF, Wade S, Sandborn WJ. A cost-effectiveness analysis of alternative disease management strategies in patients with Crohn's disease treated with azathioprine or 6-mercaptopurine. Am J Gastroenterol 2005; 100:2239-47. [PMID: 16181376 DOI: 10.1111/j.1572-0241.2005.41900.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Azathioprine (AZA) is effective for the maintenance of a steroid free remission in Crohn's disease (CD). Thiopurine methyltransferase (TPMT) is important for the metabolism of AZA and influences the production of active AZA metabolites. AZA dose selection based on pharmacogenetic testing of TPMT and metabolite monitoring (MM) may offer a safety and efficacy advantage over traditional dosing strategies. We performed a decision analysis to estimate the potential costs and effectiveness of TPMT screening and MM as disease management strategies for CD. METHODS Strategies applying TPMT and/or MM to influence treatment decisions were compared to community care (CC). The impact on toxicity minimization and improved time to initial and sustained response was evaluated. A 1-yr model was developed from the third-party payer perspective for mild to moderately chronically active, steroid-treated CD patients. Effectiveness and toxicity defined by time to response CD activity index (CDAI <150, +/- steroids) or time to sustained response (CDAI <150, off steroids x 8 wk) and reduction in leukopenic events, respectively. One- and two-way sensitivity analyses were conducted to determine the effect of varying individual estimates from those used in the base-case analysis. RESULTS MM, TPMT, and TPMT + MM strategies as compared to CC achieved an earlier time to initial response (18.66, 18.96, and 19.10 vs. 22.41 wk, respectively) and sustained response (39.83, 42.91, and 39.8 vs. 45.36 wk, respectively). The least costly strategy at 1 yr was TPMT ($3,861) and the most costly strategy was CC ($7,142). Each alternative strategy was shown to dominate CC (i.e., less costs and faster time to response or sustained response). The cost-effectiveness rankings were robust to sensitivity analyses on key variables. CONCLUSION The addition of alternative strategies to CC may improve AZA outcomes and reduce the total cost of care for steroid treated chronically active CD patients, with TPMT being more beneficial for initial response to treatment and MM being more beneficial for sustained response to treatment.
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Becker C. A profit-thinner. Hospitals, docs await substitute for risky warfarin. MODERN HEALTHCARE 2005; 35:32-3. [PMID: 16101253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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Chalmers RJG, Kirby B, Smith A, Burrows P, Little R, Horan M, Hextall JM, Smith CH, Klaber M, Rogers S. Replacement of routine liver biopsy by procollagen III aminopeptide for monitoring patients with psoriasis receiving long-term methotrexate: a multicentre audit and health economic analysis. Br J Dermatol 2005; 152:444-50. [PMID: 15787812 DOI: 10.1111/j.1365-2133.2005.06422.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients receiving long-term methotrexate for psoriasis are at risk of developing hepatic fibrosis. Repeated liver biopsy has long been regarded as the only reliable method of detecting this and it is still recommended by the American Academy of Dermatology (AAD). More recently, monitoring by serum procollagen III aminopeptide (PIIINP) measurement (Orion Diagnostica, Espoo, Finland) has been advocated as a means of significantly reducing the need for liver biopsy. OBJECTIVES To assess the validity of guidelines developed in Manchester for the use of PIIINP to monitor patients with psoriasis receiving long-term methotrexate; to assess the anticipated benefits to patients of introducing this change in practice, including reduction in requirement for liver biopsy; and to determine the impact of its introduction on healthcare costs. METHODS A multicentre audit was conducted over a 24-month period to compare the healthcare costs and outcomes of two intervention groups from centres where serial PIIINP measurement was employed with those of two control groups from centres in which AAD guidelines were followed. RESULTS A sevenfold reduction in the need for liver biopsy was observed in the two intervention groups (n = 166; 0.04 and 0.02 biopsies/patient/year, respectively) compared with the two control groups (n = 87; 0.26 and 0.30 biopsies/patient/year, respectively). Abnormalities of sufficient severity to influence management were identified in one in five patients biopsied in the main intervention group compared with one in 16 in the control groups. The overwhelming majority of patients surveyed expressed a preference for being monitored by methods that would minimize the need for liver biopsy. The adoption of PIIINP for monitoring would result in significant cost savings. CONCLUSIONS This audit has shown that patients managed by the Manchester protocol using serial PIIINP measurement and selective liver biopsy were not disadvantaged in comparison with those managed according to AAD guidelines; they were subjected to sevenfold fewer liver biopsies without evidence that important liver toxicity was missed in the process. If PIIINP monitoring were widely adopted, methotrexate would become a more acceptable option for many patients who are dissuaded from considering it because of the threat of repeated liver biopsy; it would also result in significant savings to the healthcare budget.
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Kiser JJ, Anderson PL, Gerber JG. Therapeutic drug monitoring: Pharmacologic considerations for antiretroviral drugs. Curr HIV/AIDS Rep 2005; 2:61-7. [PMID: 16091250 DOI: 10.1007/s11904-005-0020-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Therapeutic drug monitoring (TDM) is the process by which a patient's dosing regimen is guided by repeated measures of plasma drug concentrations. An enormous challenge with regard to TDM of antiretroviral drugs (ARV) is that the concentration goals can be moving targets. Well-designed prospective studies demonstrating that prospectively altering ARV doses based on TDM leads to virologic success and increased tolerability are needed. Nevertheless, there are specific clinical instances where this experimental intervention should be considered to potentially reduce toxicity and improve therapeutic outcomes.
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Kassam R, Vaillancourt R, Trottier M, Gervais A. Evaluation of pharmacist-managed nonprescription drug benefit for Canadian military personnel. J Am Pharm Assoc (2003) 2005; 45:170-8. [PMID: 15868759 DOI: 10.1331/1544345053623591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether (1) desirable health outcomes (e.g., symptom resolution) would be achieved with a new national drug-management program implemented by the Canadian Forces (CF); (2) CF members would be satisfied with the services offered by the civilian pharmacists; and (3) cost implications of the new program would be favorable. DESIGN Open, nonrandomized, longitudinal program evaluation and cost analysis study. SETTING Canada. PARTICIPANTS 583 CF members who did not have access to a military pharmacy in selected geographic areas of Canada and 65 community pharmacy providers. INTERVENTION A new drug-management program, which allowed members to obtain nonprescription medications from civilian pharmacies without first obtaining a prescription from a physician at no additional cost, was evaluated in a pilot study. MAIN OUTCOME MEASURES A cost-analysis model conducted from the CF Health Services and Department of National Defense perspectives and telephone survey assessing health outcomes and members' satisfaction with the program. RESULTS Based on 563 transactions that occurred during the pilot study period, 96% of the CF members reported being very to somewhat satisfied with the service received under the new drug-management program, and a majority stated that desirable health outcomes were achieved. The one area of concern cited about the new program was the low percentage of members who recalled being instructed by civilian pharmacists to see a physician if their symptoms did not abate. The cost analysis showed the new program was more economical than previous physician-based system. CONCLUSION The provision of nonprescription medications by civilian pharmacists to members who had no access to a base pharmacy was both cost-efficient and associated with a high level of satisfaction. Future evaluations should include prospective monitoring of drug use patterns as well as assessments of the quality of care.
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Jones TE, Smith BJ, Polasek JF. Pharmacoeconomics of low-molecular-weight heparins: limitations of studies comparing them to unfractionated heparin. Expert Opin Pharmacother 2005; 5:1887-97. [PMID: 15330727 DOI: 10.1517/14656566.5.9.1887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Unfractionated heparin (UFH) entered medical usage in the 1930s and was the mainstay of acute anticoagulation until the 1980s, when low-molecular-weight heparins (LMWHs) became available. At this time, the acquisition cost of LMWHs, being greater than that of UFH, was a significant barrier to their use even though there was evidence that this was offset by savings in monitoring and other areas. Evidence of the superiority of LMWHs over UFH in many clinical settings has been accumulating and, along with economic analyses that have demonstrated overall cost savings when LMWH is compared to UFH, has resulted in rapidly expanding sales of LMWH, whereas sales of UFH, are in decline. In addition to being more effective than UFH, LMWHs may cause less bleeding, are less likely to cause heparin-induced thrombocytopenia (HIT) and exhibit less inter-patient variability. In addition to the savings from reduced monitoring, the greater acquisition costs for LMWHs are also offset by reduced costs of treating adverse effects and unprevented venous thromboembolism. LMWHs are usually administered once daily via the subcutaneous route, and this often allows treatment to be undertaken in the community rather than in hospitals, thereby saving considerable sums on inpatient costs. Pharmacoeconomic analyses are limited by a variety of factors including geographical and temporal variability in cost inputs, cost shifting, cost inputs that are omitted and payer perspective. Some of these limitations, including the economic impact of HIT and the savings in hospital costs, will be discussed. The effect of changes in acquisition costs since their introduction and the potential impact of medicolegal costs, will also be explored. Settings where evidence of benefit of LMWH over UFH is lacking will also be discussed.
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Abstract
There are a number of effective but highly toxic drugs that exhibit a narrow therapeutic index and marked interpatient pharmacokinetic variability. Individualized therapy with such drugs requires therapeutic drug monitoring (TDM) to obtain the desired clinical effects safely. Cost-effectiveness analysis in health care is still at an early stage of development, especially for TDM. A systematic review was carried out to document studies that have addressed the cost-effectiveness of TDM. The Cochrane database and Medline were searched. References identified by this approach were then searched manually for relevant articles. Very few studies have been performed that document the cost-effectiveness of TDM, and TDM has been demonstrated to be cost-effective only for aminoglycosides. For the other classes of drugs that are monitored, the rationale for TDM has been supported, but appropriate cost-effectiveness analyses have not been performed. Because the use of many of these drugs without TDM would increase the risk of under- or overdosing, emphasis should not be placed solely on cost-effectiveness but rather on how such interventions can be applied in the most cost-effective and clinically useful manner.
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Rogers G. Patient self-management of oral anticoagulation. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2005; 3:94-5. [PMID: 16166974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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Kohno H. [Clinical evaluation of therapeutic drug monitoring]. NIHON RINSHO. JAPANESE JOURNAL OF CLINICAL MEDICINE 2004; 62 Suppl 12:351-5. [PMID: 15658336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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82
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The economics of anticoagulation: what are the issues? THE AMERICAN JOURNAL OF MANAGED CARE 2004; 10:S292-6. [PMID: 15605699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Jankovic SM. The clinical pharmacology departments should develop their services according to the local health care needs. Eur J Clin Pharmacol 2004; 60:381-2. [PMID: 15221159 DOI: 10.1007/s00228-004-0791-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2004] [Accepted: 05/14/2004] [Indexed: 11/25/2022]
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Tredger JM, Brown NW, Adams J, Gonde CE, Dhawan A, Rela M, Heaton N. Monitoring mycophenolate in liver transplant recipients: toward a therapeutic range. Liver Transpl 2004; 10:492-502. [PMID: 15048791 DOI: 10.1002/lt.20124] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Predose plasma mycophenolic acid (MPA) concentrations measured with a semi-automated enzyme-multiplied immunoassay were related to adverse events (e.g., rejection, leukopenia, infection), drug dose, and clinical status in 147 adult and 63 pediatric liver allograft recipients receiving adjunctive immunosuppression with mycophenolate mofetil (MMF). In 12 of 13 acute rejection episodes, predose MPA levels were below the 1 mg/L cut-off defined using receiver operating characteristic (ROC) curve analysis. The relative risk of developing infection or leukopenia increased more than 3-fold above predose MPA levels of 3 to 4 mg/L. Plasma MPA levels correlated weakly (r2 = 0.081) with MMF dose and the dose / level relationship was variably influenced by age, the indication for MMF, concentrations of serum albumin and creatinine, and comedication with tacrolimus or cyclosporine. The median mycophenolate dose required per unit mycophenolate level was 50% lower in children than in adults. Comparable drug requirements were also decreased by renal dysfunction (by 40 and 43% in adults and children, respectively), and in patients prescribed MMF alone rather than with tacrolimus or cyclosporine. However, in patients with serum albumin less than 35 g/L, MMF dose requirements were higher than in those with normal albumin levels (by 2.1- and 2.6-fold in adults and children, respectively). In adults, 44.7% achieved clinically acceptable therapeutic MPA concentrations at a dose less than 1 g MMF twice daily and only 6.3% required 1.5 g twice daily as suggested by the manufacturer. The immunoassay was a rapid, reliable, and acceptably precise technique in which only 10.8% of measurements were unproductive. In conclusion, our data suggests that MPA predose level monitoring is both clinically- and cost-effective and that a therapeutic range of 1 to 3.5mg/L (by immunoassay) is applicable in liver allograft recipients given adjunctive MMF.
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Machin SJ. Ximelagatran, a new oral anticoagulant--how will it affect laboratory practice? A clinical perspective. LABORATORY HEMATOLOGY : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR LABORATORY HEMATOLOGY 2004; 10:172-3. [PMID: 15529439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Keown PA, Kiberd B, Balshaw R, Khorasheh S, Marra C, Belitsky P, Kalo Z. An economic model of 2-hour post-dose ciclosporin monitoring in renal transplantation. PHARMACOECONOMICS 2004; 22:621-632. [PMID: 15244488 DOI: 10.2165/00019053-200422100-00001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Monitoring of microemulsion ciclosporin (cyclosporine; Neoral) by 2-hour post-dose drug concentrations (C2) is an accurate measure of ciclosporin absorption efficiency and exposure, and appears superior to trough (C0) monitoring for prediction of rejection risk. A predictive decision model was used to determine if this approach also reduces total treatment costs in the first 12 months after renal transplantation. METHODS Parameter estimates for key clinical events were derived from the literature and from prospective pharmacokinetic studies comprising 234 adult HLA-non-identical renal graft recipients at seven Canadian centres. Patients were treated with microemulsion ciclosporin (Neoral), corticosteroids and azathioprine or mycophenolate mofetil. Using the perspective of the Canadian healthcare provider, total treatment costs for the C2 versus the C0 strategy were modelled over 12 months, and then remodelled using conservative estimates to extend the timeframe to 5 years. Health resources were valued in 1999 Canadian dollars. RESULTS The incidence of acute rejection was estimated to be 25% at 1 year in patients monitored by C0 and 18% in those monitored by C2. Patient survival was considered to be independent of monitoring strategy, and graft loss was predicted to be 1.4% lower in the C2 group. The studies suggested no important differences in comorbidity and the costs of C0 and C2 monitoring and ambulatory-based adverse events were held equivalent. Using these inputs, the average cost per patient for the first year post-transplant was Can dollars 46,857 for C0 monitoring and Can dollars 45,306 for C2 monitoring, rising to Can dollars 146,879 and Can dollars 142,569 after 5 years. The predicted cost for initial hospitalisation was Can dollars 11,280 for C0 and Can dollars 10,806 for C2 monitoring. The cost of maintenance immunosuppressive drug use, graft loss and dialysis was Can dollars 19,098 in the C0 group and Can dollars 18,612 in the C2 group, while acute rejection treatment costs were Can dollars 2169 and Can dollars 1577, respectively. An additional Can dollars 14,310 was consumed by other events, including repeat hospitalisation, for each group. Sensitivity analysis indicated that the most influential parameters affecting savings due to C2 monitoring were a reduction in the duration of initial and follow-up hospitalisations and reduced risks of acute rejection and subsequent graft loss. CONCLUSIONS Compared with traditional trough concentration monitoring, ciclosporin monitoring at 2 hours post-dose produced a predicted saving of Can dollars 1551 during the first year after renal transplant. Although modelling assumptions become more restrictive over time, this projection allows a preliminary assessment of the long-term economic impact of the routine use of C2 monitoring.
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Rakhmanina NY, van den Anker JN, Soldin SJ. Therapeutic drug monitoring of antiretroviral therapy. AIDS Patient Care STDS 2004; 18:7-14. [PMID: 15006189 DOI: 10.1089/108729104322740866] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The concept of managing pharmacotherapy based on plasma drug concentrations has been used for decades in a variety of clinical settings. The interest in therapeutic drug monitoring (TDM) of antiretroviral drugs has grown significantly since highly active antiretroviral therapy (HAART) became a standard of care in clinical practice. A primary characteristic of TDM of antiretroviral drugs is that multiple agents are concomitantly used in HAART regimens. Inadequate drug concentrations may lead to evolution of drug resistance mutations and endanger present and future treatment options. A number of clinical trials have demonstrated that drug serum concentrations are an important factor in response to therapy for HIV, but whether TDM will become a tool for the routine management of HIV infection remains to be determined. This review includes an illustrative case report of measuring concentrations of antiretroviral drugs in a pediatric patient.
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Benjamin DK, Miller WC, Ryder RW, Weber DJ, Walter E, McKinney RE. Growth patterns reflect response to antiretroviral therapy in HIV-positive infants: potential utility in resource-poor settings. AIDS Patient Care STDS 2004; 18:35-43. [PMID: 15006193 DOI: 10.1089/108729104322740901] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Laboratory monitoring of HIV-infected children is the current standard of care in the United States to guide the appropriate use of antiretroviral therapy (ART). Although ART is becoming a reality in some developing countries, laboratory monitoring of ART is costly, necessitating creative approaches to monitoring. As an initial step to guide monitoring of HIV progression in low resource settings, we assessed the utility of the physical examination to predict clinical progression of HIV. We conducted a retrospective cohort study of HIV-infected children using data from Pediatric AIDS Clinical Trials Group Protocol 300. We developed a clinical predictive model, and compared the utility of the clinical model to the change in HIV RNA viral load as diagnostic tests of ART failure. The clinical model incorporated treatment regimen, age, and height velocity: a three-level clinical predictive model provided likelihood ratios of 0.3, 3.9, and 14. For decline in RNA the likelihood ratios were 0.2 (> 1 log decline), 1.4, and 3.5 (> log increase). We developed a simple clinical predictive model that was able to predict clinical progression of HIV after initiation of new ART. The clinical model performed similarly to using changes in HIV RNA viral load. These data should be validated internationally and prospectively, because the test subjects were from a resource rich environment and growth patterns in undernourished children may be impacted differently by HIV and its treatment. The model was most pertinent to children 36 months of age or younger, and was conducted in children receiving monotherapy and dual therapy.
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Bálint GS. [New methods of monitoring therapeutic drug levels]. Orv Hetil 2003; 144:2590-1. [PMID: 15005071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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91
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[Anticoagulation in atrial fibrillation. Instead of costly therapy control soon a tablet for all?]. MMW Fortschr Med 2003; 145:8. [PMID: 14724987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
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Donnerer J, Kronawetter M, Kapper A, Haas I, Kessler HH. Therapeutic Drug Monitoring of the HIV/AIDS Drugs Abacavir, Zidovudine, Efavirenz, Nevirapine, Indinavir, Lopinavir, and Nelfinavir. Pharmacology 2003; 69:197-204. [PMID: 14624060 DOI: 10.1159/000073664] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2003] [Accepted: 06/25/2003] [Indexed: 11/19/2022]
Abstract
Combination therapy with antiretroviral drugs is used for the treatment of patients infected with the human immunodeficiency virus. To achieve optimal drug concentrations for viral suppression and avoidance of drug toxicity, monitoring of drug levels has been considered essential. We set up an analytical procedure for monitoring the plasma concentrations of a total of seven drugs: abacavir, zidovudine, efavirenz, nevirapine, indinavir, lopinavir, and nelfinavir. The plasma samples were liquid/liquid extracted and subjected to high-performance liquid chromatography (HPLC) analysis. The compounds were monitored by ultraviolet detection: indinavir, lopinavir, and nelfinavir at 215 nm; efavirenz at 254 nm, and abacavir, zidovudine, and nevirapine at 266 nm. Two different extraction procedures and two different HPLC eluents on a C(8) reversed-phase HPLC column were used to monitor all seven compounds. Under steady state conditions, the plasma concentrations of antiviral drugs in 175 patients were correlated with the time after the last dosing to define the peak or trough levels. Due to the short plasma elimination half-life of abacavir and zidovudine, only peak levels could be determined for these compounds, whereas both peak and trough levels could be assessed for the other compounds because of a longer plasma elimination half-life. The mean peak concentrations (microg/ml) were 0.69 for abacavir and 0.57 for zidovudine; the mean peak/trough concentrations (microg/ml) were 2.07/1.32 for efavirenz, 2.43/2.23 for nevirapine, 5.48/1.08 for indinavir, 4.69/3.51 for lopinavir, and 3.54/1.45 for nelfinavir. The described analytical method offers a broad-spectrum monitoring of plasma levels of antiretroviral drugs.
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McCahon D, Fitzmaurice DA, Murray ET, Fuller CJ, Hobbs RFD, Allan TF, Raftery JP. SMART: self-management of anticoagulation, a randomised trial [ISRCTN19313375]. BMC FAMILY PRACTICE 2003; 4:11. [PMID: 13678426 PMCID: PMC240084 DOI: 10.1186/1471-2296-4-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2003] [Accepted: 09/18/2003] [Indexed: 11/10/2022]
Abstract
BACKGROUND Oral anticoagulation monitoring has traditionally taken place in secondary care because of the need for a laboratory blood test, the international normalised ratio (INR). The development of reliable near patient testing (NPT) systems for INR estimation has facilitated devolution of testing to primary care. Patient self-management is a logical progression from the primary care model. This study will be the first to randomise non-selected patients in primary care, to either self-management or standard care. METHOD The study was a multi-centred randomised controlled trial with patients from 49 general practices recruited. Those suitable for inclusion were aged 18 or over, with a long term indication for oral anticoagulation, who had taken warfarin for at least six months. Patients randomised to the intervention arm attended at least two training sessions which were practice-based, 1 week apart. Each patient was assessed on their capability to undertake self management. If considered capable, they were given a near patient INR testing monitor, test strips and quality control material for home testing. Patients managed their own anticoagulation for a period of 12 months and performed their INR test every 2 weeks. Control patients continued with their pre-study care either attending hospital or practice based anticoagulant clinics. DISCUSSION The methodology used in this trial will overcome concerns from previous trials of selection bias and relevance to the UK health service. The study will give a clearer understanding of the benefits of self-management in terms of clinical and cost effectiveness and patient preference.
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Harrison MJ. Challenges in assessing costs of rheumatoid arthritis. THE CASE MANAGER 2003; 14:65-72; quiz 73. [PMID: 14593350 DOI: 10.1016/s1061-9259(03)00208-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Olson DM, Chioffi SM, Macy GE, Meek LG, Cook HA. Potential benefits of bispectral index monitoring in critical care. A case study. Crit Care Nurse 2003; 23:45-52. [PMID: 12961782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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Abstract
The use of therapeutic drug monitoring (TDM) in the treatment of HIV-infection is gaining momentum in resource-rich countries. However, data justifying its use is still in short supply. In this manuscript we review the necessary components of TDM before it should be implemented in widespread clinical use. In addition, we provide specific examples of clinical situations where TDM is likely to useful. The overall conclusion of this review is that TDM is a promising therapeutic modality for improving antiretroviral efficacy and reducing toxicity. However, more prospective clinical trials are necessary in order to validate the therapeutic concentrations of antiretroviral drugs suggested by various investigators. In addition, both the clinical utility and cost effectiveness of TDM will need to be demonstrated by well-designed and adequately powered clinical trials in both antiretroviral nai;ve and experienced subjects. At this point in time we consider TDM in the treatment of HIV-infection as experimental with significant promise for the future.
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Darko W, Medicis JJ, Smith A, Guharoy R, Lehmann DE. Mississippi mud no more: cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin to prevent nephrotoxicity. Pharmacotherapy 2003; 23:643-50. [PMID: 12741439 DOI: 10.1592/phco.23.5.643.32199] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin to prevent nephrotoxicity. An analysis was performed for subpopulations of patients receiving nephrotoxic agents (aminoglycosides, amphotericin, and acyclovir), those in the intensive care unit, and those on the oncology service. METHODS Decision analysis was used to model the cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin. The reference case was determined, in part, by a retrospective review of 200 patients randomly selected from our clinical pharmacology consultation service. Patients were aged 18 years or older and had received intravenous vancomycin for at least 48 hours, with at least two--one peak and one trough--vancomycin serum concentrations obtained during therapy. Results of published clinical trials were used to determine the probability of vancomycin-induced nephrotoxicity. RESULTS The mean cost of treating nephrotoxicity was 11,233 dollars at our institution. The mean cost for all patients was 25,166 dollars (sensitivity analysis 15,000-27,500 dollars)/nephrotoxic episode prevented. The subgroup analysis revealed a cost of 8,363 dollars (sensitivity analysis 4,368-10,500 dollars)/nephrotoxic episode prevented in intensive care patients, 5,000 dollars (sensitivity analysis 1,687-13,250 dollars ) in oncology patients, and a dominant strategy showing a cost savings of 5,564 dollars (sensitivity analysis 2,724-12,428 dollars) in those receiving concomitant nephrotoxins. CONCLUSION Although pharmacokinetic monitoring and dosage adjustment are effective methods for reducing the toxicity of many drugs, controversy exists regarding the necessity of such monitoring with vancomycin. Evaluation by decision analysis over a range of assumptions, varying probabilities, and costs reveals that pharmacokinetic monitoring and vancomycin dosage adjustment to prevent nephrotoxicity are not cost-effective for all patients. However, such dosage adjustment demonstrates cost-effectiveness for patients receiving concomitant nephrotoxins, intensive care patients, and probably oncology patients.
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Patel KR, Uber LA. Leading the way: development of an interdisciplinary pharmaceutical outcomes management program. Gastroenterol Nurs 2003; 26:127-8. [PMID: 12811324 DOI: 10.1097/00001610-200305000-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Glencross DK, Mendelow BV, Stevens WS. Laboratory monitoring of HIV/AIDS in a resource-poor setting. S Afr Med J 2003; 93:262-3. [PMID: 12806710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
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Niiranen S, Lamminen H, Niemi K, Mattila H, Kalli S. A cost study of new media supported near oral anticoagulant treatment follow-up. Int J Med Inform 2003; 70:19-29. [PMID: 12706179 DOI: 10.1016/s1386-5056(02)00179-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE In this study we sought to develop a comparative cost evaluation between conventional and new media, e.g. web, mobile communication technology and digital television, and near patient testing supported anticoagulant (ac) treatment follow-up in a primary health care setting. METHOD The comparison was done for two patient groups, self-care and home-care patients, on oral ac treatment in the primary health care centre of the rural and sparsely populated municipality of Ikaalinen. In practise case analysis was used to develop cost functions from collected economic data, which were analysed to determine the break-even point in total cost between conventional and new media supported follow-up for the two patient groups. RESULTS In the home-care setting the break-even point is 14 patients; in the self-care setting new media supported follow-up is always more cost-effective. CONCLUSION The results illustrate that the use of new media and near patient testing in ac treatment follow-up brings about an economic benefit even with a small number of patients in the Ikaalinen setting. However, the sensitivity of break-even to perturbations in the individual costs of the used economic models remains high. Still, when the economic benefits are considered together with the clinical and practical benefits shown to result from self-testing, self-management and use of new media technologies the new service models can be said to provide noticeable benefits both in terms of quality of care and economics in our specific setting.
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