Pharmacoeconomics: a challenge for clinical pharmacologists

Medicine and Phlebolymphology: Time to Change?

Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

[Pharmacoeconomics: basic concepts and applications to clinical anesthesia]

The economic evaluation of medications and health care technology has gained importance in recent years. Health care resources are limited and their use must be optimized so that we can take the greatest possible advantage. Pharmacoeconomics seeks to analyze the best therapeutic drug choices to obtain the desired outcome in specific cases or in populations. The 4 approaches used in pharmacoeconomics are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. This review examines the characteristics of each type of study using examples from anesthesiology, a field in which pharmacoeconomics is beginning to play a role.

Drugs, money and society (Part II)

Pharmacoeconomics started as marketing but has developed into a valuable tool in the fuller assessment of drug therapies. Its principles are now widely accepted, and many countries have government-funded agencies with responsibility for its application, most notably the National Institute for Health and Clinical Excellence in England. Many clinical pharmacologists are active in this area, and the discipline itself is part of the clinical pharmacology trainees' curriculum. Further developments will include value-based pricing and its use in cost sharing arrangements between health service and manufacturers.

Cost-Effectiveness Analysis of Tiotropium Compared to Ipratropium and Salmeterol

OBJECTIVE

The constant increase in health care costs, in a context of limited resources and the appearance of more costly though more effective drugs, justifies an assessment of the pharmacoeconomics of these drugs. The objective of this study was to evaluate the cost-effectiveness of one of the newest drugs for the treatment of chronic obstructive pulmonary disease (COPD)-tiotropium.

MATERIAL AND METHOD

A cost-effectiveness analysis (costs and outcomes) within the framework of the Spanish National Health System was done. The alternatives to tiotropium analyzed were ipratropium and salmeterol. Direct health care costs associated with hospital treatment were calculated. Forced expiratory volume in 1 second, quality of life (with the Saint George's Respiratory Questionnaire), dyspnea transitional index, mean stay in hospital, and exacerbations were the variables used to measure effectiveness. Values for these variables were taken from the main reviews and randomized clinical trials published for tiotropium.

RESULTS

For COPD patients, treatment with tiotropium leads to a greater reduction in exacerbations (37% compared to ipratropium and 25% compared to salmeterol 25%), and a reduction in the number of days in hospital (33% compared to ipratropium and 14% compared to salmeterol). Therefore, use of tiotropium could save ;100 000 for the current rates of admission and lengths of hospital stay in Spain.

CONCLUSIONS

Tiotropium was more effective than ipratropium and salmeterol as measured by objective clinical variables (forced expiratory volume in 1 second) and subjective ones (the Saint George's Respiratory Questionnaire and dyspnea transitional index). Hospital stays were shorter and exacerbations fewer with tiotropium. In all cases, tiotropium was more cost-effective than the alternatives, thus use of tiotropium could help hospitals to save money.

Expanding the role of the infection control professional in the cost-effective use of antibiotics

There is a growing demand that health care expenses be contained and that excessive and inappropriate use of antibiotics be eliminated. At the University of California, San Diego Medical Center, strategies aimed at controlling drug usage and subsequently reducing costs have been implemented and found to be effective. Mechanisms designed to achieve such goals without diminishing quality of care involve expanding the role of the infection control professional (ICP) while implementing antibiotic control stratagems such as antimicrobial utilization teams, antibiotic order sheets, audits of use, automatic stop orders, computer-assisted management, drug use reviews, educational efforts, formulary practice, restricted drug policies, and target drug monitoring. The infection control professional, as well as other members of the antimicrobial utilization team, contributes to the promotion of the appropriate use of antibiotics in part by identifying individual cases in which antibiotics might be used inappropriately, such as for the treatment of colonization rather than infection or when appropriate microbiologic testing has not been carried out.