Impact of systemic hypertension on the cardiovascular benefits of statin therapy--a meta-analysis

The ASCOT-LLA and ALLHAT-LLT trials provide conflicting evidence of the efficacy of statins in decreasing cardiovascular (CV) morbidity and mortality in hypertensive patients. We performed a meta-analysis to compare the overall efficacy of statins in hypertensive and nonhypertensive patients enrolled in major randomized clinical trials. We systematically reviewed PubMed publications from 1985 onward for placebo-controlled randomized trials that examined the effect of statins on cardiac morbidity and mortality. Only trials that followed >or=1,000 patients for >or=2 years were included in the meta-analysis. Outcomes included cardiac or CV death, major coronary events, or major CV events. Pooled estimates of relative risk (RR) were calculated separately for hypertensive and nonhypertensive patients. The moderating effect of the percentage of hypertensive patients at baseline was tested using meta-regression. Besides the ASCOT-LLA and ALLHAT-LLT, 12 trials enrolling 69,984 patients met inclusion criteria. Overall, in these 12 trials, statin therapy decreased cardiac death by 24% (RR 0.76, 95% confidence interval [CI] 0.71 to 0.82). There was no evidence of difference in RR estimates for hypertensive (RR 0.78, 95% CI 0.72 to 0.84) and nonhypertensive (RR 0.76, 95% CI 0.72 to 0.80) patients. Similarly, meta-regression showed that the efficacy of statins was not moderated by the percentage of hypertensive patients at baseline (Q estimate 1.51, p=0.22). In conclusion, statin therapy effectively decreases CV morbidity and mortality to the same extent in hypertensive and nonhypertensive patients.

Evaluating the adequacy of disease control in patients with rheumatoid arthritis: a RAND appropriateness panel

OBJECTIVES

There is a lack of agreement on assessing disease activity in patients with RA and determining when the RA treatment should be changed or continued. A panel of rheumatologists was convened to develop guidelines to assess adequacy of disease control, focusing on the use of disease-modifying anti-rheumatic drugs.

METHODS

The Research and Development/University of California in Los Angeles (RAND/UCLA) Appropriateness Method was used to evaluate disease control adequacy. After a literature review, 108 scenarios were developed to simulate situations most likely to be encountered in clinical practice and rated on a 9-point scale by a 10-member expert panel.

RESULTS

Final appropriateness rankings for the scenarios were as follows: 37% 'appropriate', 48% 'inappropriate', and 16% 'neutral'. The panelists felt that patients with disease control in the 'appropriate' range have adequate control with their current therapy, whereas those in the 'inappropriate' range should be considered for a change in therapy. Those in 'neutral' areas should have their therapy reviewed carefully. The panelists recommended that the clinically active joint count should be considered the most important decision factor. In patients with no clinically active joints, regardless of other factors no change in therapy was felt to be warranted. Patients with five or more active joints should be considered inadequately treated, and in patients with one to four active joints other variables must be considered in the decision to change therapy.

CONCLUSION

These preliminary guidelines will assist the clinician in determining when a patient's clinical situation warrants therapy escalation and when continuing the current regimen would be appropriate.

Disease-specific cost savings of treating nighttime versus daytime gastroesophageal reflux disease in an employed population

OBJECTIVE

The extent to which proton pump inhibitors (PPIs) can offset direct medical costs by reducing symptoms related to gastroesophageal reflux disease (GERD) in order to improve work productivity is not well understood. This study aimed to evaluate the economic impact of treating GERD with PPIs versus no treatment, from an employer's perspective.

STUDY DESIGN

An economic model was developed to simulate symptom reduction and breakthrough symptoms as well as associated costs over 1 year among a population of 100,000 with a 20% GERD prevalence rate. Medical costs, including GERD-related office visits, hospitalisations and procedures, were delineated by symptom severity. Indirect costs represented the monetised work productivity loss. PPI treatment costs $2/day (standard dose).

RESULTS

The GERD burden was substantial ($62,500,000). Treatment yielded $32,600,000 in savings ($1,630 saved/patient/year), mostly from reducing indirect costs. Treatment produced greater savings among nighttime GERD patients throughout the PPI cost range ($1-$5/day). Savings dropped if the price of standard doses of PPI exceeded $3.92/day for the treatment of daytime GERD patients.

Economic burden of cardiovascular events and fractures among patients with end-stage renal disease

OBJECTIVE

To quantify direct medical costs of fractures and cardiovascular diseases among end-stage renal disease (ESRD) patients.

METHODS

Medicare claims data from year 2001 of the United States Renal Data System were used to quantify direct medical costs of acute episodic events (acute myocardial infarction (MI), stroke, heart valve repair, heart valve replacement, fractures) and chronic conditions (arrhythmia, peripheral vascular disease (PVD), heart valve disease (HVD), congestive heart failure (CHF), coronary heart disease, and non-acute stroke). Costs of hospitalized episodes of arrhythmia, PVD, CHF, and angina were also quantified. For acute events, costs were quantified using an episode-of-care approach. For chronic conditions, annualized costs were reported. Only costs specific to the events or conditions of interest were included and reported, in 2006 US dollars. Drug and dialysis-related costs were excluded. Diagnosis and procedure codes were used to identify these events and conditions.

RESULTS

Among acute events analyzed as clinical episodes, PVD ($358 million) was associated with the greatest economic burden, followed by CHF, arrhythmia, angina, acute MI, heart valve replacement, hip fracture, acute stroke, heart valve repair, vertebral fracture, and pelvic fracture ($8.6 million). The cost per episode ranged from approximately $12,000 to 104,000. Among chronic conditions, CHF ($681 million) contributed the greatest economic burden; HVD ($100 million) contributed the least. The costs per patient-year ranged from $23,000 to 45,000 among chronic conditions. The costing methodology utilized could contribute to an underestimate of the economic impact of each condition; therefore these results are considered conservative.

CONCLUSION

The economic burden of these selected conditions was substantial to health services payers who finance ESRD patient care. Episodic costs were high for most acute events.

A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding

OBJECTIVES

Abnormal uterine bleeding (AUB) impacts women's health-related quality of life (HRQoL) and puts a heavy economic burden on society. To date, this burden has not been systematically studied. We conducted a systematic review of the medical literature to evaluate the impact of AUB on HRQoL and to quantify the economic burden of AUB from a societal perspective.

METHODS

We searched the PubMed and Cochrane databases, and article bibliographies for the period up to July 2005. Teams of two reviewers independently abstracted data from studies that reported outcomes of interest: prevalence, HRQoL, work impairment, and health-care utilization and costs associated with AUB.

RESULTS

The search yielded 1009 English-language articles. Ninety-eight studies (including randomized controlled trials, observational studies, and reviews) that met the inclusion and exclusion criteria underwent a full-text review. The prevalence of AUB among women of reproductive age ranged from 10% to 30%. The HRQoL scores from the 36-item Short-Form Health Survey Questionnaire (SF-36) suggested that women with AUB have HRQoL below the 25th percentile of that for the general female population within a similar age range. The conservatively estimated annual direct and indirect economic costs of AUB were approximately $1 billion and $12 billion, respectively. These figures do not account for intangible costs and productivity loss due to presenteeism.

CONCLUSIONS

The burden of AUB needs further and more thorough investigation. Additional research should prospectively evaluate the impact of AUB and the value of treatment provided to help guide future health resource allocation and clinical decision-making.

Consequences of frequent nocturnal gastro-oesophageal reflux disease among employed adults: symptom severity, quality of life and work productivity

BACKGROUND

Effects of frequent nocturnal symptoms of gastro-oesophageal reflux disease (GERD-FNS) on health-related quality of life (HRQOL) and work productivity are not well documented.

AIM

To assess symptom severity, production loss, and HRQOL among employed adults with and without GERD-FNS.

METHODS

Using several validated outcome measures in a web survey design, GERD was pre-specified as GERD Symptom and Medication Questionnaire score >9, and > or =1 episode of heartburn or acid regurgitation during the preceding week. GERD-FNS patients were those reporting > or =2 symptom-nights during the previous week; their outcomes were compared with those of patients having minimal or no nocturnal symptoms (GERD-NNS) and vs. non-GERD controls.

RESULTS

Data were collected from 1002 GERD patients (476 GERD-FNS, 526 GERD-NNS) and 513 controls. Severe symptoms were more common, sleep abnormalities were more frequent (P < 0.0001) and SF-36 scores lower (P < 0.05, all scores) among GERD-FNS patients vs. GERD-NNS patients. GERD-related work loss was greater among those with GERD-FNS vs. GERD-NNS (P < 0.0001). Work loss and functional limitations were more pronounced when comparing GERD-FNS cases vs. non-GERD controls.

CONCLUSION

Employed adults with frequent nocturnal GERD report more severe symptoms, and are associated with impaired sleep, HRQOL and work productivity compared with controls and patients with minimal or no nocturnal symptoms.

Treatment of patients with metastatic renal cell cancer: a RAND Appropriateness Panel

BACKGROUND

New developments in the treatment of patients with metastatic renal cell cancer (MRCC) have suggested a need to reevaluate the role of systemic therapies. The authors convened a panel of medical and urologic oncologists to rate the appropriateness of the main options.

METHODS

The authors used the RAND/University of California-Los Angeles Appropriateness Method to evaluate systemic therapy options and cytoreductive nephrectomy. After a comprehensive literature review, an expert panel rated the appropriateness of systemic options (108 permutations) and cytoreductive nephrectomy (24 permutations) for patients with MRCC.

RESULTS

The appropriateness evaluation indicated that 27.3% of permutations were rated "appropriate," 46.9% were rated "inappropriate," and 25.8% were rated "uncertain." There was a high rate of agreement (95%). Sunitinib and sorafenib were rated appropriate for patients with low-to-moderate risk regardless of prior treatment. Temsirolimus was rated appropriate for first-line therapy for higher risk patients. Interferon-alpha and low-dose interleukin-2 were rated inappropriate or uncertain. In patients who received prior immunotherapy, cytokines were rated inappropriate. In all permutations for evaluating systemic therapy, enrollment into an investigational trial was considered appropriate, treatment with bevacizumab was uncertain, and thalidomide was inappropriate regardless of risk status or prior therapy. For good surgical risk patients with planned immunotherapy, nephrectomy was rated appropriate in patients who had limited metastatic burden regardless of tumor-related symptoms and in symptomatic patients regardless of metastatic burden. Only the most favorable combination of surgical risk, metastatic burden, and symptoms generated an "appropriate" rating for patients with planned targeted therapy.

CONCLUSIONS

The current results begin the process of defining an appropriate role for cytokines, newer targeted therapies, and surgery in the treatment of MRCC.

Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism

PURPOSE

A study was conducted to evaluate compliance with the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy guidelines for the prevention of venous thromboembolism (VTE) in hospitals.

METHODS

Using the HealthFacts database, hospitalized patients, age 40 years or more, with medical conditions at risk for VTE (surgical, trauma, and acute spinal injury patients) were identified. Hospital admissions on or after January 1, 2001, and concluded by March 31, 2005, were included if they met any of the following conditions as defined in the ACCP Consensus Conference on Antithrombotic Therapy guidelines: patients at risk of VTE medical conditions, major orthopedic surgery, general surgery, gynecological surgery, urologic surgery, trauma, neurosurgery, and acute spinal cord injury. Hospitalizations were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The primary objective was to examine whether patients received one of the indicated anticoagulants at the proper dosage and during the relevant hospital days as determined in the ACCP guidelines. Rates of compliance were assessed, and the reasons for guideline noncompliance were also determined.

RESULTS

The overall compliance rate with ACCP guidelines was 13.3% (ranging from 2.8% for neurosurgery to 52.4% for orthopedic surgery) in the 123,304 hospital admissions that were reviewed. Only 15.3% of patients with at-risk medical conditions received prophylaxis in accordance with ACCP guidelines. Potential reasons for guideline noncompliance among selected conditions included the omission of prophylaxis, inadequate prophylaxis duration, and the wrong type of anticoagulant.

CONCLUSION

A retrospective study found low rates of compliance with guidelines for thromboprophylaxis.

Appropriate treatment for Crohn's disease: methodology and summary results of a multidisciplinary international expert panel approach--EPACT

BACKGROUND/AIMS

For many therapeutic decisions in Crohn's disease (CD), high-grade evidence is lacking. To assist clinical decision-making, explicit panel-based appropriateness criteria were developed by an international, multidisciplinary expert panel.

METHODS

10 gastroenterologists, 3 surgeons and 2 general practitioners from 12 European countries assessed the appropriateness of therapy for CD using the RAND Appropriateness Method. Their assessment was based on the study of a recent literature review of the subject, combined with their own expert clinical judgment. Panelists rated clinical indications and treatment options using a 9-point scale (1 = extremely inappropriate; 9 = extremely appropriate). These scenarios were then discussed in detail at the panel meeting and re-rated. Median ratings and disagreement were used to aggregate ratings into three assessment categories: appropriate (A), uncertain (U) and inappropriate (I).

RESULTS

569 specific indications were rated, dealing with 9 clinical presentations: mild/moderate luminal CD (n = 104), severe CD (n = 126), steroid-dependent CD (n = 25), steroid-refractory CD (n = 37), fistulizing CD (n = 49), fibrostenotic CD (n = 35), maintenance of medical remission of CD (n = 84), maintenance of surgical remission (n = 78), drug safety in pregnancy (n = 24) and use of infliximab (n = 7). Overall, 146 indications (26%) were judged appropriate, 129 (23%) uncertain and 294 (52%) inappropriate. Frank disagreement was low (14% overall) with the greatest disagreement (54% of scenarios) being observed for treatment of steroid-refractory disease.

CONCLUSIONS

Detailed explicit appropriateness criteria for the appropriate use of therapy for CD were developed for the first time by a European expert panel. Disease location, severity and previous treatments were the main factors taken into account. User-friendly access to EPACT criteria is available via an Internet site, www.epact.ch, allowing prospective evaluation and improvement of appropriateness of current CD therapy.

Evolution of clinical practice guidelines: evidence supporting expanded use of medicines

Previous studies have shown that the primary factor underlying increased spending on pharmaceuticals has been the rising utilization of medications, rather than increases in unit drug price. This study examined the evolution of clinical practice guidelines to assess possible reasons for the rising drug volume. Clinical practice guidelines from 1970 to the present were reviewed for the six most prevalent treatable medical conditions/risk factors listed as priority areas by the Institute of Medicine. We searched the National Guidelines Clearinghouse, PubMed and Medline databases, and Web sites of relevant national organizations for US clinical practice guidelines published through January 2005. Information pertaining to the therapeutic regimen (eg, the frequency and duration of recommended treatment, when treatment should be initiated, the patient population for whom the guideline was intended) was abstracted and entered into evidence tables. Changes in guidelines were distributed across three themes that recommended evidence-based increases in medication use, including: (1) changes in the size of the treatable population; (2) changes in the number and type of recommended pharmaceutical therapeutic options, including movement from monotherapy to combination therapy, treatment of comorbidities, and use of newer types of medicines; and (3) changes in the therapeutic regimen, including a shift from episodic care to preventive and chronic care. Many of these changes point to an important, but not often noticed, addition of secondary prevention of disease effects to the objectives of medical care. These trends are likely to continue with important economic, clinical, and policy ramifications.

Review of eight pharmacoeconomic studies of the value of biologic DMARDs (adalimumab, etanercept, and infliximab) in the management of rheumatoid arthritis

BACKGROUND

Treatment options for the management of rheumatoid arthritis (RA) have expanded from the traditional disease-modifying antirheumatic drugs (DMARDs) to include the biologic DMARDs that inhibit tumor necrosis factoralpha (TNF-a).

OBJECTIVE

To assess the medical literature for studies of the economic value of biologic DMARDs, specifically the 3 TNF-a inhibitors (adalimumab, etanercept, and infliximab) used for the management of RA, compared with the traditional DMARDs such as sulfasalazine, antimalarials, penicillamine, gold, methotrexate, azathioprine, leflunomide, and cyclophosphamide.

METHODS

A comprehensive search of the MEDLINE and HealthSTAR databases was conducted to identify cost-efficacy, cost-effectiveness, or cost-utility studies published in the English language (from 1966 through November 2004). The search terms and/or MeSH (medical subject headings) titles were cost-benefit analysis, rheumatoid arthritis, antirheumatic agents, antineoplastic and immunosuppressive agents. Studies were critically reviewed and quality was assessed using the Quality of Health Economic Studies instrument. Most studies evaluated the use of biologics among RA patients resistant to DMARDs. Studies were assessed with regard to comparators evaluated, measures of efficacy, perspectives, model duration, treatment duration, and discount rate.

RESULTS

From 180 titles identified, 155 were excluded for the following reasons: 89 because they did not consider the drugs of interest, 15 because the population was not RA, 19 because of having the wrong drugs and population, 22 because they were review articles, and 10 because they were general articles. Twentyfive abstracts were accepted for further review. Of these, 13 abstracts were subsequently selected for full-text review. One of the authors identified a study not indexed in MEDLINE. Ultimately, 2 cost-effectiveness and 6 cost-utility studies were selected for this critical review. One study over 6 months reported that triple therapy with DMARDs (methotrexate-hydroxychloroquine-sulfasalazine) was cost effective for methotrexate-resistant patients, which is consistent with American College of Rheumatology (ACR) guidelines that support the use of triple therapy prior to biologics. The incremental cost-effectiveness ratio (ICER) was $1,500 per patient to achieve an ACR20 response for this triple therapy compared with no second-line agent. Overall, biologic therapies cost considerably more than traditional DMARDs but produced more quality-adjusted life-years (QALYs). Despite differences in design and assumptions, published economic models consistently reported ICERs <50,000 dollars per QALY gained for biologics compared with traditional DMARDs, although ICERs of >100,000 dollars were reported from sensitivity analyses.

CONCLUSIONS

Clinical guidelines currently recommend the use of biologics as step therapy after failure of traditional DMARDs. Reported ICERs comparing biologics with traditional DMARDs are within a range that is comparable with other accepted medical interventions. The worth of the additional expenditure will ultimately be judged by formulary and policy decision makers because no maximum cost has been defined. Models can be used to inform decision makers, but they must be interpreted and applied carefully. More research is also needed to differentiate the relative economic value of the various biologic agents by therapeutic indication.

Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception

OBJECTIVE

This study aims to compare the cost-effectiveness of oral contraceptives (OCs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and surgical management in treating dysfunctional uterine bleeding (DUB) in women not desiring additional children.

METHOD

A Markov model was constructed from the perspective of the health services payers for a 5-year period. Treatment costs, DUB treatment success rates and contraception success rates were obtained through a literature review.

RESULTS

In women not responding to an initial trial of OCs, surgical management was more effective than the LNG-IUS (95.5% vs. 92%) but at higher cost (US$4853 vs. US$2796 per woman). Among responders to OCs, continuing treatment with the LNG-IUS instead of OCs was more effective (92% vs. 90.4%) and less expensive (US$2796 vs. US$4711). For women naïve to medical therapy, the LNG-IUS and OCs had similar effectiveness, but cost for the LNG-IUS was lower (US$2796 vs. US$4895). In all scenarios, surgery followed if medical therapy failed; rates of primary method failure were 62.5% with OCs and 34% with the LNG-IUS at 12 months.

CONCLUSIONS

Treatment strategies employing the LNG-IUS are the most cost-effective in managing DUB, regardless of whether a woman has previously tried OC therapy.

Review of eight pharmacoeconomic studies of the value of biologic DMARDs (adalimumab, etanercept, and infliximab) in the management of rheumatoid arthritis

BACKGROUND

Treatment options for the management of rheumatoid arthritis (RA) have expanded from the traditional disease-modifying antirheumatic drugs (DMARDs) to include the biologic DMARDs that inhibit tumor necrosis factoralpha (TNF-a).

OBJECTIVE

To assess the medical literature for studies of the economic value of biologic DMARDs, specifically the 3 TNF-a inhibitors (adalimumab, etanercept, and infliximab) used for the management of RA, compared with the traditional DMARDs such as sulfasalazine, antimalarials, penicillamine, gold, methotrexate, azathioprine, leflunomide, and cyclophosphamide.

METHODS

A comprehensive search of the MEDLINE and HealthSTAR databases was conducted to identify cost-efficacy, cost-effectiveness, or cost-utility studies published in the English language (from 1966 through November 2004). The search terms and/or MeSH (medical subject headings) titles were cost-benefit analysis, rheumatoid arthritis, antirheumatic agents, antineoplastic and immunosuppressive agents. Studies were critically reviewed and quality was assessed using the Quality of Health Economic Studies instrument. Most studies evaluated the use of biologics among RA patients resistant to DMARDs. Studies were assessed with regard to comparators evaluated, measures of efficacy, perspectives, model duration, treatment duration, and discount rate.

RESULTS

From 180 titles identified, 155 were excluded for the following reasons: 89 because they did not consider the drugs of interest, 15 because the population was not RA, 19 because of having the wrong drugs and population, 22 because they were review articles, and 10 because they were general articles. Twentyfive abstracts were accepted for further review. Of these, 13 abstracts were subsequently selected for full-text review. One of the authors identified a study not indexed in MEDLINE. Ultimately, 2 cost-effectiveness and 6 cost-utility studies were selected for this critical review. One study over 6 months reported that triple therapy with DMARDs (methotrexate-hydroxychloroquine-sulfasalazine) was cost effective for methotrexate-resistant patients, which is consistent with American College of Rheumatology (ACR) guidelines that support the use of triple therapy prior to biologics. The incremental cost-effectiveness ratio (ICER) was $1,500 per patient to achieve an ACR20 response for this triple therapy compared with no second-line agent. Overall, biologic therapies cost considerably more than traditional DMARDs but produced more quality-adjusted life-years (QALYs). Despite differences in design and assumptions, published economic models consistently reported ICERs <50,000 dollars per QALY gained for biologics compared with traditional DMARDs, although ICERs of >100,000 dollars were reported from sensitivity analyses.

CONCLUSIONS

Clinical guidelines currently recommend the use of biologics as step therapy after failure of traditional DMARDs. Reported ICERs comparing biologics with traditional DMARDs are within a range that is comparable with other accepted medical interventions. The worth of the additional expenditure will ultimately be judged by formulary and policy decision makers because no maximum cost has been defined. Models can be used to inform decision makers, but they must be interpreted and applied carefully. More research is also needed to differentiate the relative economic value of the various biologic agents by therapeutic indication.

Systematic review: the lower gastrointestinal adverse effects of non-steroidal anti-inflammatory drugs

BACKGROUND

Lower gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs) are much more poorly characterized than upper gastrointestinal effects.

AIM

To determine if NSAIDs increase lower gastrointestinal adverse effects and if the risk with non-selective NSAIDs is greater than with cyclooxygenase-2-selective inhibitors (coxibs).

METHODS

Computerized databases were searched to identify studies of NSAID use reporting on lower gastrointestinal integrity (e.g. permeability), visualization (e.g. erosions, ulcers) and clinical events.

RESULTS

Designs in 47 studies were randomized (18), case-control (14), cohort (eight) and before-after (seven). Non-selective-NSAIDs had significantly more adverse effects vs. no NSAIDs in 20 of 22 lower gastrointestinal integrity studies, five of seven visualization studies, seven of 11 bleeding studies (OR: 1.9-18.4 in case-control studies), two of two perforation studies (OR: 2.5-8.1) and five of seven diverticular disease studies (OR: 1.5-11.2). Coxibs had significantly less effect vs. non-selective-NSAIDs in three of four integrity studies, one endoscopic study (RR mucosal breaks: 0.3), and two randomized studies (RR lower gastrointestinal clinical events: 0.5; haematochezia: 0.4).

CONCLUSIONS

An increase in lower gastrointestinal injury and clinical events with non-selective-NSAIDs appears relatively consistent across the heterogeneous collection of trials. Coxibs are associated with lower rates of lower gastrointestinal injury than non-selective-NSAIDs. More high-quality trials are warranted to more precisely estimate the effects of non-selective-NSAIDs and coxibs on the lower gastrointestinal tract.

When is it appropriate to prescribe postmenopausal hormone therapy?

OBJECTIVE

To develop evidence and consensus-based recommendations for the use of hormone therapy (HT) in postmenopausal women.

DESIGN

Using evidence from clinical trials and other publications, a multidisciplinary group of women's health experts developed consensus-based recommendations for HT use in more than 300 clinical scenarios. These panelists utilized the RAND Appropriateness Method and a quantitative scale to rate the appropriateness of treatment options for women with various risk factors and clinical scenarios.

RESULTS

The panel judged it appropriate to prescribe all forms of HT to women with intolerable menopause symptoms and usual (age-expected) risks of cardiovascular disease (CVD), venous thromboembolism (VTE), or stroke. Use of HT was judged not appropriate for the clinical scenarios of bone preservation, cosmetic appearance, current memory loss, loss of libido, or CVD protection. For a woman still using HT after 5 or more years, it was considered appropriate to recommend the options of stopping or lowering the dose even if stopping was previously attempted. In treating intolerable symptoms in the presence of some elevated risk for diseases related to HT, route of administration may affect appropriateness but prior stroke or TIA# is a contraindication.

CONCLUSIONS

Standard HT is appropriate for women with intolerable menopause symptoms in the absence of HT-related risk factors (eg, CVD, stroke, VTE, breast cancer). Panelists judged it appropriate to repeatedly present the option of stopping or reducing the dose. In most cases, presence of risk factors makes standard-dose oral HT not appropriate; however, some women may be candidates for a different dose or route of administration.

Septicemia in Patients with ESRD Is Associated with Decreased Hematocrit and Increased Use of Erythropoietin

Septicemia, a common complication in chronic dialysis patients, may be an important factor in erythropoietin (EPO) hyporesponsiveness, because it is a form of inflammation. The quantitative impact of septicemia on EPO requirements has not been studied. The purpose of this study was to analyze patterns of EPO use and levels of anemia among patients who had ESRD and were hospitalized with septicemia. Using United States Renal Data System data, septicemia admissions were identified in patients with first ESRD service from 1996 to 2001. Mean EPO dosage and hematocrit (Hct) level were analyzed from 2 mo before until 3 mo after admission and compared with patients who were hospitalized with acute myocardial infarction (AMI) and patients with no hospitalizations. A total of 4640 hospitalized patients were included in the analysis: 3975 for septicemia and 665 for AMI. In both groups, mean Hct declined significantly in the month of admission and increased in the second month after admission. At all time points, both groups had significantly lower Hct levels compared with the nonhospitalized group. Mean EPO dosage increased, most rapidly in the month after admission. EPO use was highest in the septicemia group. Hospitalization with septicemia is associated with worsening anemia and increasing EPO use. This also was observed for patients who were hospitalized with AMI, suggesting that acute intercurrent illness plays an important role in EPO hyporesponsiveness. Strategies to prevent septicemia are important not only to decrease clinical morbidity but also to conserve EPO usage and thus contain the costs of care for this complex patient population.

Identification, diagnosis, and management of anemia in adult ambulatory patients treated by primary care physicians: evidence-based and consensus recommendations

OBJECTIVE

Provide recommendations for the identification, diagnosis, and management of ambulatory patients with anemia.

MATERIALS AND METHODS

The RAND/UCLA Appropriateness Method was used to develop the recommendations. A literature review of anemia prevalence (based on a search of PubMed for the period 1990 to 2003), etiology, and treatment outcomes was reviewed by a panel comprised of nine physicians (six primary care, three specialists) who then rated 336 clinical scenarios and grouped them into three categories: 'appropriate', 'uncertain', or 'inappropriate'.

RESULTS

Performing a complete blood count on a yearly basis was rated 'appropriate' for patients with an underlying chronic condition, for men > or = 50 years old, and for all women with no chronic condition on an every-5-years basis. Specific recommendations were made for five anemia management options (observation, referral, empiric trial of iron, transfusion, and erythropoietic growth factors). Recommendations for observation alone were based on age, gender, and hemoglobin level. Immediate referral to a gastroenterologist or hematologist for a work-up was rated 'inappropriate' in all cases. An empiric trial of iron was rated 'inappropriate' for women over age 40 and for all men. Recommendations on the use of erythropoietic growth factors were based on hemoglobin level and anemia symptoms ('appropriate' if Hb < 9.5 g/dL, or if Hb = 9.5-11.0 g/dL and anemia symptoms were present). Finally, recommendations about transfusion were based on the severity of anemia and the presence of cardiovascular disease ('appropriate' in patients > or = 70 years old and in those presenting with either symptoms of anemia or underlying cardiovascular disease). The recommendations did not address anemia related to nutritional deficiencies, cancer/chemotherapy, or chronic renal failure.

CONCLUSION

Primary care physicians should obtain screening blood counts, perform diagnoses, and manage anemia in patient groups known to be at risk. These recommendations on the identification, diagnosis, and management of anemia represent an opportunity to improve outcomes in ambulatory patients with anemia.

Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis

OBJECTIVE

There is a rapidly evolving debate on the indications and appropriate duration of therapy for postmenopausal hormone therapy. The objective of this meta-analysis was to examine the specific relationships of postmenopausal estrogen therapy (ET), postmenopausal combined (estrogen-progestogen) hormone therapy (CHT), and the incidence of breast cancer.

DESIGN

We performed computerized searches of MEDLINE and CancerLit through September 2003 and reviewed reference lists of retrieved studies and meta-analyses. We included English-language studies that identified noncontraceptive postmenopausal hormone use; reported on the risks of "current use" of ET and/or CHT and breast cancer incidence; were case-control, cohort, or experimental; and reported either an odds ratio (OR), relative risk (RR), or HR with CIs. Two investigators were involved during all stages of study selection and independently extracted all data selected for inclusion in meta-analyses.

RESULTS

Meta-analysis of 13 studies of ET and breast cancer (700,000 women) resulted in an OR of 1.16 (95% confidence limits [CL] 1.06, 1.28), with estimates for less than 5 years use 1.16 (1.02, 1.32) and more than 5 years use 1.20 (1.06, 1.37). Meta-analysis of eight studies of CHT and breast cancer (650,000 women) resulted in an OR of 1.39 (95% CL 1.12, 1.72), with estimates for less than 5 years use 1.35 (1.16, 1.57) and more than 5 years use 1.63 (1.22, 2.18).

CONCLUSIONS

Data from observational studies support the association of increased but considerably different risks for breast cancer incidence among current users of ET and CHT. These represent the first pooled estimates for ET. CHT estimates correspond to those from randomized trials.

Clinical and economic outcomes of Staphylococcus aureus septicemia in ESRD patients receiving hemodialysis

BACKGROUND

Serious infections are a common problem in patients with end-stage renal disease (ESRD). The purpose of this study is to identify clinical and economic consequences of hospitalizations for septicemia caused by Staphylococcus aureus in hemodialysis patients with ESRD.

METHODS

We conducted a retrospective analysis of data obtained from the US Renal Data System to determine lengths of stay and Medicare paid costs for index hospitalizations and episodes of care for patients with ESRD hospitalized with septicemia caused by S aureus. Factors associated with hospital length of stay and Medicare paid costs were examined in multivariate analysis.

RESULTS

A total of 11,572 patient admissions with septicemia caused by S aureus were included; 20.7% of patients developed 1 or more complications. Average length of stay for the index admission was 13.0 days, and 11.8% of patients were readmitted within 12 weeks for care related to S aureus. Average Medicare cost for the index admission was 17,307 dollars. Average episodic cost of care, including the index hospitalization, outpatient visits, and readmissions related to S aureus during the subsequent 12 weeks, was 20,067 dollars. S aureus--related complications were associated with greater episodic costs of care: no complications, 18,476 dollars; one complication, 25,804 dollars (P < 0.05 versus no complications); and 2 or more complications, 32,102 dollars (P < 0.05 versus no complications). In multivariate analysis, complications resulted in increased mean lengths of stay of 4 to 7 days, and complications were among the strongest predictors of total episodic costs.

CONCLUSION

Patients with septicemia caused by S aureus had costly and lengthy hospitalizations, which frequently were associated with clinically and economically important complications, including hospital readmissions.

A critical assessment of treatment options for idiopathic pulmonary fibrosis

BACKGROUND

To date, no management approach has proven to be efficacious for the treatment of idiopathic pulmonary fibrosis (IPF). Consequently, therapeutic options remain controversial and confusing for many clinicians. We sought to formally review available evidence on treatment options for IPF and to have a diverse panel of physicians rate the "appropriateness," "inappropriateness," or "uncertainty" of some of the available therapeutic options.

METHODS

The RAND/UCLA Appropriateness Method was used to review and rate multiple clinical scenarios for the treatment of IPF. The panel was composed of nine physicians from geographically diverse areas who received a systematic review on the risks and benefits of commonly used treatments for IPF as background.

RESULTS

A total of 324 clinical scenarios were rated: 25% as appropriate; 39%, uncertain; and 36%, inappropriate. The panel disagreed about 12% of the therapy indications in the final ratings, falling from 26% in the first-round ratings.

CONCLUSIONS

Key themes emerged from the consensus process. Lacking evidence for a definitive therapy, it was considered most appropriate to enroll eligible patients in clinical trials and refer eligible patients for transplant evaluation. For patients without access to clinical trials, the committee was not unanimous regarding treatment recommendations. It was considered inappropriate for patients with a confident diagnosis of IPF to be treated with corticosteroids as the sole agent: corticosteroids should be used in conjunction with azathioprine. With progressive disease despite such combination use, there was agreement for the use of interferon gamma-1b in patients unwilling or unable to participate in available clinical trials.

Economic burden of anemia in an insured population

OBJECTIVE

Anemia is a common hematological disorder characterized by reduced hemoglobin concentrations. Despite information on prevalence and associated outcomes, little is known about the impact of anemia on health care utilization and costs. This study examines anemia prevalence and associated medical costs and utilization, using administrative claims for adults newly diagnosed with anemia, including up to 12 months of follow-up.

METHODS

Patients predisposed to anemia, based on selected comorbid conditions (chronic kidney disease, human immunodeficiency virus, rheumatoid arthritis, inflammatory bowel disease, congestive heart failure, and solid-tumor cancers), were identified. Costs for anemic patients and a random sample of nonanemic patients with these conditions were compared. Associations were evaluated after adjustment for potential confounders using a regression model. Clinical care patterns were examined overall and by condition.

RESULTS

Anemia was observed in 3.5% (81,423) of approximately 2.3 million health plan members in 2000; 15% of anemic patients received an identified treatment, with transfusion being the most frequent intervention. Utilization and costs were significantly higher for anemic patients (P < 0.001). Average annualized per-patient costs were 14,535 US dollars for anemic patients (55% outpatient, 33% inpatient, 13% pharmacy), 54% higher than the 9,451 US dollars average cost for nonanemic patients (45% outpatient, 36% inpatient, 19% pharmacy). After adjustment for age, other comorbidities (e.g., chronic kidney disease and cancer), sex, and insurance type (indemnity, preferred provider organization/point of service, or health maintenance organization, in the Medstat MarketScan database), anemic patients had average costs that were more than twice the adjusted costs of nonanemic patients.

CONCLUSION

Medical costs for anemic patients are as much as twice those for nonanemic patients with the same comorbid conditions.

Determining the appropriateness of selected surgical and medical management options in recurrent stroke prevention: A guideline for primary care physicians from the National Stroke Association work group on recurrent stroke prevention

Despite a decade of successful clinical trials for stroke prevention, substantial gaps exist in the application and implementation of this information in community practice. The frequency of guideline use is low, and there remains controversy regarding the standard of practice. Patients with stroke may have multiple risk factors and concomitant stroke mechanisms, factors that are not addressed in stroke clinical trials and guideline statements. New guidelines are needed to account for these complexities and to provide primary care physicians a practical means to achieve stroke prevention. We sought to develop guidelines that can be implemented by primary care physicians to enhance the use of medical and surgical measures for recurrent stroke prevention. We sought to test the applicability of current evidence-based guidelines to daily practice with routine and complex patient case scenarios to determine whether these could be simplified into a more easily applied form for primary care physicians. We used RAND/UCLA Appropriateness Methodology to develop guidelines for the use of interventions supported by randomized controlled trials including carotid revascularization, anticoagulant therapy, antiplatelet therapy, and blood pressure management for the prevention of recurrent stroke. After a systematic literature review of randomized clinical trials we developed a comprehensive list of indications or clinical scenarios to capture decision making. A diverse multidisciplinary panel reviewed and rated each indication according to the RAND Appropriateness Method. First, panelists rated each scenario (1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate) without interaction with other panelists. "Appropriate" was defined as the expected health benefit exceeding its expected negative consequences by a sufficient margin. At a formal interactive session, panelists re-rated all indications. Overall carotid endarterectomy was rated as appropriate when there was 50% to 99% ipsilateral symptomatic carotid artery stenosis, inappropriate with <50% or 100% stenosis (total occlusion), and uncertain when the surgical risk was high. Carotid angioplasty was generally rated as of uncertain value. When there was atrial fibrillation, anticoagulation with warfarin was rated as appropriate when there was a low bleeding risk but of uncertain value when the bleeding risk was high. For patients who were not candidates for warfarin therapy, aspirin, aspirin plus extended-release dipyridamole, or clopidogrel were all rated as appropriate initial therapies. Ticlopidine was considered inappropriate and aspirin plus clopidogrel of uncertain value. With the exception of ticlopidine and aspirin, persons with a prior cerebral ischemic event while on aspirin could receive any of the aforementioned antiplatelet agents or combinations and be considered appropriately treated. The panelists rated a blood pressure of <130/80 mm Hg at 1 year after ischemic stroke as the target level and rated any of the following agents as appropriate initial therapies if there was no diabetes mellitus or proteinuria: diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin-converting enzyme receptor blockers, or combinations of a diuretic and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patient risk played a significant role in deterring the panel from recommending certain therapies; however, the presence of atrial fibrillation or large or small cerebral vessel syndromes rarely had significant influence on treatment decisions. Appropriateness was less where bleeding or surgical risk was excessive. Using consensus evidence from clinical trials, we have developed recurrent stroke prevention guidelines for routine and more complex patient scenarios according to appropriateness methodology. Broad application of these guidelines in primary practice promises to reduce the burden of recurrent stroke.