Impact of Medicare Part D for Medicare-age adults with arthritis: prescription use, prescription expenditures, and medical spending from 2005 to 2008

OBJECTIVE

To evaluate the impact of Medicare Part D on medication utilization, drug expenditures, and medical expenditures in patients with arthritis.

METHODS

This was a retrospective study using a national sample of 2,484 Medicare-eligible beneficiaries with arthritis from the pooled Medical Expenditure Panel Survey 2005-2008 data. Quantile regression was used to estimate the following outcomes: 1) number of prescription fills, 2) total drug expenditures, 3) out-of-pocket (OOP) drug expenditures, 4) Medicare-paid drug expenditures, 5) total medical expenditures (including all payments for inpatient/outpatient care, prescription drugs, and other medical services), 6) OOP medical expenditures, and 7) Medicare-paid medical expenditures. For each outcome variable, the 50th, 75th, and 90th percentiles were estimated, adjusting for demographics and comorbidity. All expenditures were inflation adjusted to 2008 dollars.

RESULTS

From 2005 to 2008, the adjusted median annual number of prescription fills increased by 4.2 (14.6% change), from 28.4 to 32.6. The adjusted median OOP drug expenditures and OOP medical expenditures decreased by $151 (25.2% change) and $197 (17.3% change), respectively. The adjusted median Medicare-paid drug and medical expenditures increased by $366 and $896 (39.5% change), respectively. The adjusted total prescription expenditures increased by $845 (25.3% change) at the 75th percentile and by $1,194 (22.0% change) at the 90th percentile. The adjusted total medical expenditures did not change significantly.

CONCLUSION

Medicare Part D resulted in increased medication utilization and significant reductions in OOP drug and OOP medical expenditures among beneficiaries with arthritis 3 years after its implementation. Part D was not associated with significant differences in total medical spending.

The state of health economic research in South Africa: a systematic review

BACKGROUND

Economic factors are a limiting factor toward the implementation of many health programmes and interventions. Economic evaluation has a great potential to contribute toward cost-effective healthcare delivery in South Africa. Little is known about the characteristics and quality of health economic (including pharmacoeconomic) research in South Africa.

OBJECTIVE AND METHODS

This study assessed the state of health economic (including pharmacoeconomic) research in South Africa. PUBMED, MEDLINE, HealthSTAR, EconLit and PsycINFO databases were searched to identify health economic articles pertaining to South Africa published between 1 January 1977 and 30 April 2010. The searches used the following Medical Subject Headings (MeSH) terms and text words alone and in combination: 'costs', 'health' and 'South Africa'. Our study included only original economic studies/analyses that pertained to South Africa, addressed a health-related topic, and had a statement or word in the title, abstract or keywords that indicated that an economic (including cost) analysis had been conducted. The study only included complete peer-reviewed publications (e.g. abstracts were excluded) that were reported in the English language. Two reviewers independently scored each article in the final sample using the data collection form designed for the study.

RESULTS

In total, 108 studies investigating a wide variety of diseases were included in the study. These articles were published in 39 different journals mostly based outside of South Africa between 1977 and 2010. On average, each article was written by three authors. Most first authors had medical/clinical training and resided in South Africa at the time of publication of their study. Based on a 1-10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.59 (SD 1.42) and half of the articles were of good quality (score 8-10) The quality of studies was related to the country in which the journal publishing the article was based (outside South Africa = higher); current residence of the primary author (outside South Africa = higher); method of economic analysis (economic evaluations higher than cost studies); type of data used (secondary higher than primary); primary training of the first author (health economics/pharmacoeconomics = higher); type of medical function (diagnosis = higher); study perspective (societal = higher); primary health intervention (pharmaceuticals = higher); study design (modelling = higher); number of authors (more = higher); and year of publication (more recent = higher) [p ≤ 0.05].

CONCLUSION

Half of the articles were of poor or fair quality. Measures are needed to promote the commissioning of more and better quality health economic and pharmacoeconomic studies in South Africa.

Assessing the quality of pharmacoeconomic studies in India: a systematic review

OBJECTIVE

The aim of the study was to evaluate the quality of pharmacoeconomic studies based in India.

METHODS

A literature search was conducted using PubMed, MEDLINE, EconLit, PsycInfo and Google Scholar to identify published work on pharmacoeconomics studies based in India. Articles were included if they were original studies that evaluated pharmaceuticals, were based in India and were conducted between 1990 and 2010. Two reviewers independently reviewed the articles using a subjective 10-point quality scale in addition to the 100-point Quality of Health Economic Studies (QHES) questionnaire.

RESULTS

Twenty-nine articles published between 1998 and May 2010 were included in the review. The included articles were published in 23 different journals. Each article was written by an average of five authors. The mean subjective quality score of the 29 articles was 7.8 (standard deviation [SD] = 1.3) and the mean QHES scores for the complete pharmacoeconomic studies (n = 24) was 86 (SD = 6). The majority of authors resided in India (62%) at the time of publication and had a medical background (90%). The quality score was significantly (p ≤ 0.05) related to the country of residence of the primary author (non-India = higher) and the study design (randomized controlled trials = higher).

CONCLUSION

Although the overall quality scores were comparable to (e.g. Nigeria) or higher than (e.g. Zimbabwe) similar studies in other developing countries, key features such as an explicit study perspective and the use of sensitivity analyses were missing in about 40% of the articles. The need for economic evaluation of pharmaceuticals is imperative, especially in developing countries such as India as this helps decision makers allocate scarce resources in a justifiable manner.

Effect of social influences on pharmacists' intention to report adverse drug events

OBJECTIVES

To identify the groups or individuals that influence pharmacists' decision making to report adverse drug events (ADEs), determine the differences in social influence or subjective norm between intenders and nonintenders, and determine the relationship between subjective norm toward reporting serious ADEs and practice and demographic characteristics.

DESIGN

Nonexperimental cross-sectional study.

SETTING

Texas during June and July 2009.

PARTICIPANTS

1,500 Texas pharmacists.

INTERVENTION

As part of a larger survey, 3 and 18 items were used to assess pharmacists' intentions and subjective norm, respectively, to report serious ADEs to the Food and Drug Administration (FDA).

MAIN OUTCOME MEASURE

Pharmacists' subjective norm toward reporting serious ADEs.

RESULTS

The survey had a response rate of 26.4% (n = 377). Most pharmacists intended to report serious ADEs that they would encounter (15.87 ± 4.22 [mean ± SD], possible range 3-21, neutral = 12). The mean subjective norm scores were moderately high and positive (28.75 ± 9.38, 1-49, 16), indicating that the referents had a moderate influence on pharmacists regarding reporting serious ADEs to FDA. FDA had the greatest (34.82 ± 12.16) and drug manufacturers the lowest (21.55 ± 13.83) social influence. The most important salient referents (important others) in pharmacists' decisions to report serious ADEs were FDA, patients, pharmacy associations, pharmacy managers/bosses, and hospitals and hospital groups. Gender (female equals higher), pharmacists' years of experience (negative correlation), and knowledge of ADE reporting (positive correlation) were associated with subjective norm.

CONCLUSION

Pharmacists had a moderately high subjective norm, suggesting that ADE reporting intentions is influenced by others and that the opinions of others are of great importance in pharmacists' intentions regarding ADE reporting. The main drivers of subjective norm were FDA, patients, pharmacy associations, and managers/bosses.

Cost-effectiveness of expanded newborn screening in Texas

OBJECTIVE

Texas House Bill 790 resulted in the expansion of the newborn screening panel from 7 disorders to 27 disorders. Implementation of this change began in 2007. The objective of this study was to estimate the incremental cost-effectiveness of the expanded newborn screening program compared with the previous standard screening in Texas.

METHODS

A Markov model (for a hypothetical cohort of Texas births in 2007) was constructed to compare lifetime costs and quality-adjusted life-years (QALYs) between the expanded newborn screening and preexpansion newborn screening. Estimates of costs, probabilities of sequelae, and utilities for disorder categories were obtained from a combination of Texas statistics, the literature, and expert opinion. A baseline discount rate of 3% was used for both costs and QALYs, with a range of 0% to 5%. Analyses were conducted from a payer's perspective, and so only direct medical cost estimates were included.

RESULTS

The lifetime incremental cost-effectiveness ratio for expanded versus preexpansion screening was about $11,560 per QALY. The results remained robust to both deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

Expanded newborn screening does result in additional expenses to the payer, but it also improves patient outcomes by preventing avoidable morbidity and mortality. The screened population benefits from greater QALYs as compared with the unscreened population. Overall, expanded newborn screening in Texas was estimated to be a cost-effective option as compared with unexpanded newborn screening.

Impact of the CATIE trial on antipsychotic prescribing patterns at a state psychiatric facility

INTRODUCTION

Results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) indicate that, with the exception of olanzapine, no substantial overall differences were identified between second generation antipsychotics (SGAs) and the first generation antipsychotic (FGA) perphenazine.

METHODS

This study evaluated the effect of CATIE on antipsychotic prescribing. A retrospective review of 1807 adults with schizophrenia was conducted and relative quarterly percentages of FGA versus SGA prescriptions were calculated.

RESULTS

Time series analysis did not identify significant differences in rates of FGA prescriptions.

CONCLUSIONS

Critiques of the methods used in CATIE may have mitigated its potential impact on antipsychotic prescribing despite cost-effectiveness of perphenazine treatment.

Review of Survey Articles Regarding Medication Therapy Management (MTM) Services/Programs in the United States

Objective: To provide a summary of published survey articles regarding the provision of medication therapy management (MTM) services in the United States. Methods: A literature search was conducted to identify original articles on MTM-related surveys conducted in the United States, involving community and outpatient pharmacists, physicians, patients, or pharmacy students and published by the primary researchers who conducted the study. Search engines used included PubMed, Medline, and International Pharmaceutical Abstracts (IPA). If MTM was in the keyword list, mesh heading, title, or abstract, the article was reviewed. References from these articles were searched to determine whether other relevant articles were available. Results: A total of 405 articles were initially reviewed; however, only 32 articles met the study requirements. Of the 32 articles, 17 surveyed community/outpatient pharmacists, 3 surveyed pharmacy students, 4 surveyed physicians, and 8 surveyed patients. The survey periods varied across the different studies, with the earliest survey conducted in 2004 and the most recent survey conducted in 2009. The surveys were conducted via the telephone, US mail, interoffice mail, e-mails, Internet/Web sites, hand-delivered questionnaires, and focus groups. Conclusion: Despite the identified barriers to the provision of MTM services, pharmacists reportedly found it professionally rewarding to provide these services. Pharmacists claimed to have adequate clinical knowledge, experience, and access to information required to provide MTM services. Pharmacy students were of the opinion that the provision of MTM services was important to the advancement of the pharmacy profession and in providing patients with a higher level of care. Physicians supported having pharmacists adjust patients’ drug therapy and educate patients on general drug information but not in selecting patients’ drug therapy. Finally, patients suggested that alternative ways need to be explored in describing and marketing MTM services for it to be appealing to them.

Evaluation of health care costs and utilization patterns for patients with gout

BACKGROUND

The prevalence of gout has been increasing. Serum uric acid (sUA) levels ≥6 mg/dL have been associated with high morbidity and increased health care utilization.

OBJECTIVE

To assess the costs and patterns of health care resource utilization for patients with gout, categorized into 3 cohorts based on sUA levels.

METHODS

We retrospectively analyzed laboratory, pharmacy, and medical service claims data (January 2005 to June 2010) for patients ≥18 years old. Inclusion criteria were at least 2 sUA levels and at least 1 primary gout diagnosis (International Classification of Disease-9th revision code 274.xx), and/or at least 1 prescription for gout-specific medications. Outcomes including costs, health care resource utilization, and medication adherence and persistence were assessed for the 1-year postindex period and summarized for the 3 cohorts based on sUA levels: <6 mg/dL, 6 to 8.99 mg/dL, and ≥9 mg/dL. Costs were adjusted based on preindex utilization and baseline characteristics.

RESULTS

Three hundred fifty-two patients met the inclusion criteria: cohort 1 (sUA <6 mg/dL), n = 38, mean age 59 years; cohort 2 (sUA 6-8.99 mg/dL), n = 231, mean age 61 years; and cohort 3 (sUA ≥9 mg/dL), n = 83, mean age 62 years. Mean adjusted gout-related health care costs were $332, $353, and $663, respectively (P <0.05); mean adjusted all-cause health care costs were $11,365, $11,551, and $14,474, respectively, for the 3 cohorts (P <0.05). sUA levels were positively associated with the percent of patients who had at least 1 hospitalization and the mean number of hospitalizations and emergency department visits (P < 0.05). Significantly more patients with sUA <6 mg/dL achieved adherence rates of ≥80% and had a longer mean duration of continuous treatment compared with patients with sUA between 6 and 8.99 mg/dL or ≥9.0 mg/dL (P <0.05).

CONCLUSIONS

Patients with high levels of sUA had higher gout-related and all-cause health care costs, more all-cause hospitalizations, and emergency department visits, but they also exhibited poorer adherence and persistence.

Adherence to oral antidiabetic medications in the pediatric population with type 2 diabetes: a retrospective database analysis

BACKGROUND

Little has been done in assessing adherence to oral antidiabetic (OAD) medications in the pediatric population presenting with type 2 diabetes. This study provided information on adherence rates in the Texas Medicaid pediatric population with type 2 diabetes, which is rare in the literature. The knowledge of adherence rates in the pediatric population with type 2 diabetes might help improve the care given to pediatric patients with type 2 diabetes.

OBJECTIVE

To describe OAD medication use, and assess trends in medication adherence and persistence among Texas pediatric Medicaid patients.

METHODS

Texas Medicaid prescription claims data of patients between 10 and 18 years of age, with at least 2 prescriptions of the same OAD medication from January 1, 2006 to December 31, 2009, were analyzed. Adherence was assessed using the medication possession ratio (MPR) as a proxy.

RESULTS

A total of 3109 patients met the study's inclusion criteria. The mean (SD) age of the 3109 eligible patients was 14.2 (2.3) years; 60% were Hispanics, 14% were blacks, 13% were whites, and another 13% were other minority races; 67% of the population were females; and 91% were on metformin of the 6 OAD medications included in the study The overall mean (SD) MPR for patients was 44.69% (27.06%). Adherence differed by gender (P < 0.0001), race (P < 0.0001), and age category (P < 0.0001). Males had higher mean (SD) MPR (47.47% [27.42%]) compared with females (43.29% [26.78%]). Mean MPR for whites (50.04% [29.65%]) was significantly higher compared with blacks (44.24% [26.16%]) and Hispanics (42.50% [26.10%]). Patients ≤12 years of age had significantly higher mean MPR (48.82% [27.37%]) compared with those in older age categories. Logistic regression analysis suggested that age was significantly related (odds ratio [OR] = 0.91; 95% CI, 0.87-0.95) to being adherent (MPR ≥80%). Males were 25% (OR = 1.25; 95% CI, 1.02-1.53; P = 0.034) more likely to be adherent (MPR ≥80%) compared with females, and whites were twice as likely to be adherent (MPR ≥80%) compared with Hispanics (OR = 2.02; 95% CI, 1.54-2.66; P = 0.0012). Overall, mean (SD) days to nonpersistence was 108 (86) days. Persistence was significantly and negatively associated with age (P < 0.0001). White race was significantly related to longer persistence.

CONCLUSION

Adherence and persistence to OAD medications in the selected Texas Medicaid pediatric population between 10 and 18 years was generally suboptimal, especially in adolescents.

Adherence, persistence of use, and costs associated with second-generation antipsychotics for bipolar disorder

OBJECTIVE

A retrospective study using Medicaid claims identified patients with bipolar disorder for whom oral second-generation antipsychotics were prescribed and compared rates of adherence, persistence of use, and costs across five groups of patients taking aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone.

METHODS

Medicaid claims data for 2,446 bipolar patients were analyzed from eight states. The 18-month observation period included the six months before and the 12 months after the index prescription date. Adherence was defined as a medication possession ratio >80%. Persistence of use was measured by the number of days of medication therapy before a 30-day gap. Mental health-related prescription costs, total prescription costs, total mental health-related costs, and total costs were assessed. Ziprasidone was the comparator.

RESULTS

Clinically recommended doses of second-generation antipsychotic medications were prescribed for 45% of the patients (N = 1,102). Of these, 58% (N = 642 of 1,102) were adherent with the prescribed medication, with no significant differences between medication groups. Median time to nonpersistence of use averaged 96 days. Patients taking olanzapine were about 35% more likely than patients taking ziprasidone to discontinue taking their medication (hazard ratio = 1.34, 95% confidence interval = 1.02-1.76, p = .04). Mental health-related prescription costs and total prescription costs were lower for risperidone than ziprasidone. No statistically significant differences were found between the groups for all mental health-related costs or total costs.

CONCLUSIONS

Among patients in a sizeable Medicaid cohort for whom a second-generation antipsychotic medication was prescribed, less than half had a clinically recommended dose, and less than two-thirds with a clinically recommended dose were adherent to the medication, confirming that many patients with bipolar disorder do not receive clinically recommended doses of second-generation antipsychotics.

Influence of attitudes on pharmacists' intention to report serious adverse drug events to the Food and Drug Administration

AIM

To investigate the influence of pharmacists' attitudes on intention to report serious adverse drug events (ADEs) to the Food and Drug Administration (FDA).

METHODS

This cross-sectional study used a mail survey to collect data from hospital and community pharmacists practicing in Texas, United States. Three and 16 items were used to measure intention and attitudes, respectively, using a seven-point bipolar scale. Pharmacists' demographic and practice characteristics, and past reporting were also measured.

RESULTS

The response rate was 26.4% (n= 377/1500 pharmacists). Most pharmacists intended (n= 297, 78.8%) to report serious ADEs that they will encounter to the FDA through MedWatch. Overall, pharmacists held favourable attitudes towards reporting serious ADEs (mean = 24.5, SD = 6.7, possible range 1-49, neutral = 16). Pharmacists intending to report serious ADEs had more favourable attitudes than those who did not (P < 0.001). About 90% of the pharmacists believed that reporting serious ADEs would improve patient safety. However, 72.6% indicated that reporting serious ADEs was time consuming and over half (55.5%) of the respondents believed that reporting serious ADEs disrupted the normal workflow. Non-intenders held stronger beliefs that ADE reporting would disrupt the normal workflow and was time consuming compared with intenders. Years of experience, number of hours worked and practice setting were associated with pharmacists' attitudes towards reporting (P < 0.05).

CONCLUSIONS

Most pharmacists held moderately favourable attitudes and high intentions toward reporting serious ADEs to the FDA. This study's findings contribute to an increased understanding of individual factors that influence pharmacists' attitude and intention towards reporting serious ADEs to the FDA.

Cost-effectiveness of lanthanum carbonate versus sevelamer hydrochloride for the treatment of hyperphosphatemia in patients with end-stage renal disease: a US payer perspective

OBJECTIVE

To assess the cost-effectiveness of lanthanum carbonate (LC) versus sevelamer hydrochloride (SH) as a treatment for hyperphosphatemia in end-stage renal disease (ESRD) patients.

METHODS

A Markov model was developed to estimate health outcomes; quality-adjusted life years (QALYs) and life-years saved (LYS), as well as associated costs. The model incorporated patient-level data from a randomized head-to-head crossover study that compared the reduction of serum phosphorus using LC and SH for 4 weeks each. The model included patients previously treated with calcium-based binders. Both the intent-to-treat (ITT) population and the cohort of patients who completed treatment in both periods of the study (i.e., completer population) were assessed. The baseline risks of cardiovascular disease (CVD), all-cause mortalities for CVD, and non-CVD patients were derived from a large US renal database. Patient outcomes were modeled for 10 years, and incremental cost-effectiveness ratios (ICERs) were calculated for LC relative to SH. Deterministic and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the base-case model.

RESULTS

For the ITT population, the ICERs of LC versus SH were $24,724/QALY and $15,053/LYS, respectively (in US dollars). When the completer population was considered, the ICERs of LC versus SH were $15,285/QALY and $9,337/LYS (Table 2), respectively. The PSA indicated 61.9% and 85.8% probabilities for ITT and completer populations of LC being cost-effective at the $50,000/QALY willingness-to-pay threshold, respectively.

CONCLUSION

LC is a cost-effective strategy compared with SH in the treatment of ESRD patients with hyperphosphatemia who were previously treated with calcium-based binders. Sensitivity analyses demonstrated the robustness of the pharmacoeconomic model.

Adherence, persistence of use, and costs associated with second-generation antipsychotics for bipolar disorder

OBJECTIVE

A retrospective study using Medicaid claims identified patients with bipolar disorder for whom oral second-generation antipsychotics were prescribed and compared rates of adherence, persistence of use, and costs across five groups of patients taking aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone.

METHODS

Medicaid claims data for 2,446 bipolar patients were analyzed from eight states. The 18-month observation period included the six months before and the 12 months after the index prescription date. Adherence was defined as a medication possession ratio >80%. Persistence of use was measured by the number of days of medication therapy before a 30-day gap. Mental health-related prescription costs, total prescription costs, total mental health-related costs, and total costs were assessed. Ziprasidone was the comparator.

RESULTS

Clinically recommended doses of second-generation antipsychotic medications were prescribed for 45% of the patients (N = 1,102). Of these, 58% (N = 642 of 1,102) were adherent with the prescribed medication, with no significant differences between medication groups. Median time to nonpersistence of use averaged 96 days. Patients taking olanzapine were about 35% more likely than patients taking ziprasidone to discontinue taking their medication (hazard ratio = 1.34, 95% confidence interval = 1.02-1.76, p = .04). Mental health-related prescription costs and total prescription costs were lower for risperidone than ziprasidone. No statistically significant differences were found between the groups for all mental health-related costs or total costs.

CONCLUSIONS

Among patients in a sizeable Medicaid cohort for whom a second-generation antipsychotic medication was prescribed, less than half had a clinically recommended dose, and less than two-thirds with a clinically recommended dose were adherent to the medication, confirming that many patients with bipolar disorder do not receive clinically recommended doses of second-generation antipsychotics.

Texas pharmacists' knowledge of reporting serious adverse drug events to the Food and Drug Administration

OBJECTIVES

To assess Texas pharmacists' knowledge of adverse drug event (ADE) reporting to the Food and Drug Administration (FDA) and to determine demographic and practice characteristics associated with this knowledge.

DESIGN

Cross-sectional descriptive study.

SETTING

Austin, TX, in June and July 2009.

PARTICIPANTS

377 pharmacists practicing in hospital and community settings.

INTERVENTION

Survey instrument mailed to participants.

MAIN OUTCOME MEASURES

Scores on an eight-item test were used to assess pharmacists' knowledge about ADE reporting to FDA. Pharmacists' demographic and practice characteristics, as well as past reporting, were also measured.

RESULTS

1,500 surveys were mailed and 377 usable responses were obtained (26.4% response rate). Most (67.9%) pharmacists had never reported ADEs to FDA. A majority of pharmacists (65.7%) reported having inadequate knowledge about ADE reporting. Pharmacists had low knowledge scores on ADE reporting, and the pass rate for all items ranged from 56.7% to 96.0%. Pharmacists' age (r = -0.106, P = 0.042) and years of experience (-0.134, P = 0.010) were negatively correlated with knowledge levels, whereas hours worked by pharmacists was positively correlated with knowledge levels (0.130, P = 0.012). Mean knowledge levels differed by practice setting, job title, and area/setting of primary place of employment (P < 0.001).

CONCLUSION

Texas pharmacists have knowledge gaps concerning ADE reporting to FDA. Pharmacists need more education, awareness, and training on ADE reporting, especially regarding reportable ADEs, how to report, and what constitutes a good report.

Generic substitution by hospital pharmacists in Thailand

The generic substitution rate by hospital pharmacists in three university affiliated outpatient hospitals in Bangkok, Thailand, was examined and the cost savings from substitution were determined using a retrospective audit of prescription forms.

A total of 3,750 prescriptions was audited (1,250 from each hospital). Of the prescriptions studied, 51.2 per cent were written for generic products, 14.5 per cent were written for brand name products obtainable from a single source and 34.2 per cent were written for brand name products obtainable from multiple sources. For multiple source brand name prescriptions, pharmacists substituted generic products 15 per cent of the time. The mean price for the multiple source brand name product was US$5.2 and the mean price of the generic substitute was $2.5, an average saving of $2.7.

The substitution rate for regular (paying) patients was 9 per cent, while the substitution rate for government assistance (poor) patients was 40 per cent. Substitution rates for the three individual hospitals were 16 per cent, 21 per cent and 9 per cent.

The authors conclude that when substitution occurs savings are substantial, but that there is potential for additional substitutions to be made.

The state of health economic evaluation research in Nigeria: a systematic review

This study assessed the state of health economic evaluation (including pharmacoeconomic) research in Nigeria. A literature search was conducted to identify health economic articles pertaining to Nigeria. Two reviewers independently scored each article in the final sample using a data collection form designed for the study. A total of 44 studies investigating a wide variety of diseases were included in the review. These articles were published in 34 different journals, mostly based outside of Nigeria, between 1988 and 2009. On average, each article was written by four authors. Most first authors had medical/clinical affiliations and resided in Nigeria at the time of publication of the study. Based on a 1 to 10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.29 (SD 1.21) and 59% of the articles were of fair quality (score 5-7); 5% were of even lower quality. The quality of articles was statistically significantly (p < or = 0.05) related to the country of residence of the primary author (non-Nigeria = higher), country of the journal (non-Nigeria = higher), primary objective of the study (economic analysis = higher) and type of economic analysis conducted (economic evaluations higher than cost studies). The conduct of health economic (including pharmacoeconomic) research in Nigeria was limited and about two-thirds of published articles were of sub-optimal quality. More and better quality health economic research in Nigeria is warranted.