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Erku D, Schneider J, Scuffham P. A framework for economic evaluation of therapeutic drug monitoring-guided dosing in oncology. Pharmacol Res Perspect 2021; 9:e00862. [PMID: 34546005 PMCID: PMC8453491 DOI: 10.1002/prp2.862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/17/2021] [Indexed: 11/18/2022] Open
Abstract
The standard approach for dose individualization of chemotherapy in the oncology setting has long been based on body surface area (BSA) as a measure of body size. However, for many anticancer drugs, administration of dosages based on BSA may result in some patients receiving supratherapeutic or subtherapeutic concentrations due to substantial interindividual pharmacokinetic variability. Therapeutic drug monitoring (TDM)-guided dosing aims to ensure that the patient's serum drug concentration is in a target range which has been shown to produce optimal clinical outcomes. The management of several malignancies is now moving away from using traditional intravenous chemotherapy to longer-term treatment with targeted molecular therapies. These targeted anticancer drugs are currently dosed based on a fixed dose for all patients. The pharmacokinetic characteristics of most of these drugs (e.g., tyrosine-kinase inhibitors) support implementation of individualized dosing via TDM. However, prior to adopting TDM-guided dosing in oncology settings, the economic efficiency and value for money of introducing TDM interventions should be critically and systematically examined along with the impacts on patient care and outcomes. Yet, current evidence in this area is limited, and more generally, there is lack of methodological guidance on how to identify, estimate and value clinical and cost information necessary to conduct economic evaluations of TDM interventions. In this paper, we propose a coherent framework for conducting economic evaluation of TDM interventions in oncology settings and discuss some practical challenges of conducting economic evaluations of TDM.
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Affiliation(s)
- Daniel Erku
- Centre for Applied Health EconomicsGriffith UniversityNathanQueenslandAustralia
- Menzies Health Institute QueenslandGriffith UniversityGold CoastQueenslandAustralia
| | - Jennifer Schneider
- School of Medicine and Public HealthThe University of NewcastleCallaghanNew South WalesAustralia
| | - Paul Scuffham
- Centre for Applied Health EconomicsGriffith UniversityNathanQueenslandAustralia
- Menzies Health Institute QueenslandGriffith UniversityGold CoastQueenslandAustralia
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Ten Ham RMT, van Nuland M, Vreman RA, de Graaf LG, Rosing H, Bergman AM, Huitema ADR, Beijnen JH, Hövels AM. Cost-Effectiveness Assessment of Monitoring Abiraterone Levels in Metastatic Castration-Resistant Prostate Cancer Patients. Value Health 2021; 24:121-128. [PMID: 33431146 DOI: 10.1016/j.jval.2020.04.1838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/28/2020] [Accepted: 04/26/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Abiraterone acetate is registered for the treatment of metastatic castration-sensitive and resistant prostate cancer (mCRPC). Treatment outcome is associated with plasma trough concentrations (Cmin) of abiraterone. Patients with a plasma Cmin below the target of 8.4 ng/mL may benefit from treatment optimization by dose increase or concomitant intake with food. This study aims to investigate the cost-effectiveness of monitoring abiraterone Cmin in patients with mCRPC. METHODS A Markov model was built with health states progression-free survival, progressed disease, and death. The benefits of monitoring abiraterone Cmin followed by a dose increase or food intervention were modeled via a difference in the percentage of patients achieving adequate Cmin taking a healthcare payer perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainties and their impac to the incremental cost-effectiveness ratio (ICER). RESULTS Monitoring abiraterone followed by a dose increase resulted in 0.149 incremental quality-adjusted life-years (QALYs) with €22 145 incremental costs and an ICER of €177 821/QALY. The food intervention assumed equal effects and estimated incremental costs of €7599, resulting in an ICER of €61 019/QALY. The likelihoods of therapeutic drug monitoring (TDM) with a dose increase or food intervention being cost-effective were 8.04%and 81.9%, respectively. CONCLUSIONS Monitoring abiraterone followed by a dose increase is not cost-effective in patients with mCRPC from a healthcare payer perspective. Monitoring in combination with a food intervention is likely to be cost-effective. This cost-effectiveness assessment may assist decision making in future integration of abiraterone TDM followed by a food intervention into standard abiraterone acetate treatment practices of mCRPC patients.
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Affiliation(s)
- Renske M T Ten Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - Merel van Nuland
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Laurens G de Graaf
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hilde Rosing
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - André M Bergman
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jos H Beijnen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anke M Hövels
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Ma Z, Li S, He D, Wang Y, Jiang H, Zhou H, Jin J, Lin N. Rapid quantification of tenofovir in umbilical cord plasma and amniotic fluid in hepatitis B mono-infected pregnant women during labor by ultra-performance liquid chromatography/tandem mass spectrometry. Rapid Commun Mass Spectrom 2020; 34:e8728. [PMID: 31960519 DOI: 10.1002/rcm.8728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 06/10/2023]
Abstract
RATIONALE Tenofovir (TFV) is a first-line antiviral agent against hepatitis B virus (HBV) and is recommended for the prevention of mother-to-infant transmission of HBV. To study the distribution of TFV in umbilical cord plasma and amniotic fluid of HBV-infected pregnant women, a rapid and sensitive method for TFV determination was developed and validated. METHODS The quantification method was developed using liquid chromatography coupled to tandem mass spectrometry (LC/MS/MS). The analytes were separated on an Acquity UPLC HSS T3 column under gradient elution with methanol and 0.01% ammonia solution in 10 mM ammonium acetate/water. This is the first reported method for the determination of TFV using alkaline rather than acidic mobile phases. Linearity, accuracy, precision, limit of quantification, specificity and stability were assessed. RESULTS Detection of TFV was achieved within 4 min. The calibration curves for TFV quantification showed excellent linearity in the range of 1-500 ng/mL. The intra- and interbatch precision and accuracy ranged from -4.35% to 6.92%. This method was successfully applied to determination of samples from 50 HBV mono-infected women undergoing tenofovir disoproxil fumarate therapy. The mean concentrations of TFV in the umbilical cord and amniotic fluid samples were 29.2 (4.6-86) and 470.9 (156-902) ng/mL, respectively, which showed a moderate positive correlation (r = 0.5299, P<0.001). CONCLUSIONS A simple, rapid but sensitive bioanalytical method to determine TFV concentration in both umbilical cord plasma and amniotic fluid using LC/MS/MS was developed and applied to HBV-infected women during labor who were undergoing TDF therapy, which will help us understand the efficacy and safety of tenofovir during pregnancy.
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Affiliation(s)
- Zhiyuan Ma
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Siying Li
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Daqiang He
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Yuqing Wang
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Huidi Jiang
- Laboratory of Pharmaceutical Analysis and Drug Metabolism, College of Pharmaceutical Sciences, Zhejiang University, Zhejiang, Hangzhou, P.R. China
| | - Hui Zhou
- Laboratory of Pharmaceutical Analysis and Drug Metabolism, College of Pharmaceutical Sciences, Zhejiang University, Zhejiang, Hangzhou, P.R. China
| | - Jie Jin
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Nengming Lin
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
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Lei Q, Zhao Y, Wang H, Zhou J, Lv X, Dang L, Zhu C. Simple and sensitive method for the analysis of 14 antituberculosis drugs using liquid chromatography/tandem mass spectrometry in human plasma. Rapid Commun Mass Spectrom 2020; 34:e8667. [PMID: 31800129 DOI: 10.1002/rcm.8667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 06/10/2023]
Abstract
UNLABELLED Monitoring plasma concentration and adjusting doses of antituberculosis (TB) drugs are beneficial for improving responses to drug treatment and avoiding adverse drug reactions. A simple and sensitive liquid chromatography/tandem mass spectrometry method was developed to measure the plasma concentrations of 14 anti-TB drugs: ethambutol, isoniazid, pyrazinamide, levofloxacin, gatifloxacin, moxifloxacin, prothionamide, linezolid, rifampin, rifapentine, rifabutin, cycloserine, p-aminosalicylic acid, and clofazimine. METHODS Human plasma was precipitated by acetonitrile and was subsequently separated by an AQ-C18 column with a gradient elution. Drug concentrations were determined using multiple reaction monitoring in positive ion electrospray ionization mode. According to pharmacokinetic data of patients, the peak concentration ranges and the timing of blood collection were determined. RESULTS Intra- and interday precision was < 14.8%. Linearity, accuracy, extraction recovery, and matrix effect were acceptable for each drug. The stability of the method satisfied different storage conditions. CONCLUSIONS The method allowed the sensitive and reproducible determination of 14 frequently used anti-TB drugs which has already been of benefit for some TB patients.
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Affiliation(s)
- Qian Lei
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Yuan Zhao
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Hao Wang
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Jun Zhou
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Xiaohui Lv
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Liyun Dang
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
| | - Changsheng Zhu
- Department of Pharmacy, Office of Drug Clinical Trial Institution and Department of Medical, Xi'an Chest Hospital, Xi'an, Shaanxi, China
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Abstract
AbstractObjectives:The purpose of the present study has been to assess the societal cost of major depression and the distribution into different cost components. The impact of adherence and treatment response was also explored.Method:Data were collected from a randomized controlled trial of patients with major depressive disorder who were treated in a naturalistic primary care setting. Resource use and quality of life were followed during the two-year trial.Results:The mean total cost per patient during two years was KSEK 363 (EUR 38 953). Indirect costs were the most important component (87%), whereas the cost of drugs was minor (4.5%). No significant differences in costs or quality of life between treatment arms or between adherent and non-adherent patients were demonstrated. However, treatment responders had 39% lower total costs per patient and experienced a larger increase in quality of life compared to non-responders.Conclusions:Major depression has high costs for society, primarily due to indirect costs. Treatment responders have considerably lower costs per patient and higher quality of life than non-responders. This indicates that measures to increase response rates are also important from an economic perspective.
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Affiliation(s)
- L von Knorring
- Department of Neuroscience, Psychiatry, Uppsala University Hospital, Uppsala University, 75185 Uppsala, Sweden.
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Fresnais M, Haefeli WE, Burhenne J, Longuespée R. Rapid drug detection in whole blood droplets using a desorption electrospray ionization static profiling approach - a proof-of-concept. Rapid Commun Mass Spectrom 2020; 34:e8614. [PMID: 31657865 DOI: 10.1002/rcm.8614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/19/2019] [Accepted: 09/26/2019] [Indexed: 06/10/2023]
Abstract
RATIONALE The introduction of desorption electrospray ionization (DESI) - and ambient desorption/ionization (ADI) ion sources in general - in the 2000s has opened new possibilities for mass spectrometric (MS) analyses of biological sample surfaces. DESI allows for a rapid screening of solid samples because no sample preparation is needed and the analysis is performed at atmospheric pressure. In the present study, we used DESI as an ion source for the rapid detection of a small molecule in blood droplets deposited on glass slides. METHODS Blood was spiked with different concentrations of a model drug, mebendazole. One microliter blood droplets of each preparation were deposited on the surface of a glass slide and analyzed by DESI, either in imaging or profiling mode. RESULTS The results suggested that DESI imaging mode was not appropriate for the detection of mebendazole in blood droplets as an initial solvation time was necessary before the obtention of signal. A profiling approach consisting of analyzing a single position of the blood droplet was used for further analysis and allowed mebendazole to be detected in the fg range and to monitor the volume of sample analyzed. CONCLUSIONS The study suggests that profiling mode at a single position is adequate for DESI analyses in whole blood droplets. This proof-of-concept study illustrates the potential of DESI profiling as a possible alternative to liquid chromatography/MS analyses of whole blood, when analyses are needed within a restricted time. Rapid detection methods in blood at atmospheric pressure may find interesting applications in the fields of toxicology and pharmacology.
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Affiliation(s)
- Margaux Fresnais
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Rémi Longuespée
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Engen NW, Hullsiek KH, Belloso WH, Finley E, Hudson F, Denning E, Carey C, Pearson M, Kagan J. A randomized evaluation of on-site monitoring nested in a multinational randomized trial. Clin Trials 2020; 17:3-14. [PMID: 31647325 PMCID: PMC6992467 DOI: 10.1177/1740774519881616] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence from prospectively designed studies to guide on-site monitoring practices for randomized trials is limited. A cluster randomized study, nested within the Strategic Timing of AntiRetroviral Treatment (START) trial, was conducted to evaluate on-site monitoring. METHODS Sites were randomized to either annual on-site monitoring or no on-site monitoring. All sites were centrally monitored, and local monitoring was carried out twice each year. Randomization was stratified by country and projected enrollment in START. The primary outcome was a participant-level composite outcome including components for eligibility errors, consent violations, use of antiretroviral treatment not recommended by protocol, late reporting of START primary and secondary clinical endpoints (defined as the event being reported more than 6 months from occurrence), and data alteration and fraud. Logistic regression fixed effect hierarchical models were used to compare on-site versus no on-site monitoring for the primary composite outcome and its components. Odds ratios and 95% confidence intervals comparing on-site monitoring versus no on-site monitoring are cited. RESULTS In total, 99 sites (2107 participants) were randomized to receive annual on-site monitoring and 97 sites (2264 participants) were randomized to be monitored only centrally and locally. The two monitoring groups were well balanced at entry. In the on-site monitoring group, 469 annual on-site monitoring visits were conducted, and 134 participants (6.4%) in 56 of 99 sites (57%) had a primary monitoring outcome. In the no on-site monitoring group, 85 participants (3.8%) in 34 of 97 sites (35%) had a primary monitoring outcome (odds ratio = 1.7; 95% confidence interval: 1.1-2.7; p = 0.03). Informed consent violations accounted for most outcomes in each group (56 vs 41 participants). The largest odds ratio was for eligibility violations (odds ratio = 12.2; 95% confidence interval: 1.8-85.2; p = 0.01). The number of participants with a late START primary endpoint was similar for each monitoring group (23 vs 16 participants). Late START grade 4 and unscheduled hospitalization events were found for 34 participants in the on-site monitoring group and 19 participants in the no on-site monitoring group (odds ratio = 2.0; 95% confidence interval: 1.1-3.7; p = 0.02). There were no cases of data alteration or fraud. Based on the travel budget for on-site monitoring and the hours spent conducting on-site monitoring, the estimated cost of on-site monitoring was over US$2 million. CONCLUSION On-site monitoring led to the identification of more eligibility and consent violations and START clinical events being reported more than 6 months from occurrence as compared to no on-site monitoring. Considering the nature of the excess monitoring outcomes identified at sites receiving on-site monitoring, as well as the cost of on-site monitoring, the value to the START study was limited.
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Affiliation(s)
- Nicole Wyman Engen
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Kathy Huppler Hullsiek
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Waldo H Belloso
- CICAL and Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Elizabeth Finley
- Washington Veterans Affairs Medical Center, Washington, D.C., United States
| | - Fleur Hudson
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Eileen Denning
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Catherine Carey
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mary Pearson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan Kagan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States
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Negoescu DM, Enns EA, Swanhorst B, Baumgartner B, Campbell JP, Osterman MT, Papamichael K, Cheifetz AS, Vaughn BP. Proactive Vs Reactive Therapeutic Drug Monitoring of Infliximab in Crohn's Disease: A Cost-Effectiveness Analysis in a Simulated Cohort. Inflamm Bowel Dis 2020; 26:103-111. [PMID: 31184366 PMCID: PMC6905301 DOI: 10.1093/ibd/izz113] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is increasingly performed for Infliximab (IFX) in patients with Crohn's disease (CD). Reactive TDM is a cost-effective strategy to empiric IFX dose escalation. The cost-effectiveness of proactive TDM is unknown. The aim of this study is to assess the cost-effectiveness of proactive vs reactive TDM in a simulated population of CD patients on IFX. METHODS We developed a stochastic simulation model of CD patients on IFX and evaluated the expected health costs and outcomes of a proactive TDM strategy compared with a reactive strategy. The proactive strategy measured IFX concentration and antibody status every 6 months, or at the time of a flare, and dosed IFX to a therapeutic window. The reactive strategy only did so at the time of a flare. RESULTS The proactive strategy led to fewer flares than the reactive strategy. More patients stayed on IFX in the proactive vs reactive strategy (63.4% vs 58.8% at year 5). From a health sector perspective, a proactive strategy was marginally cost-effective compared with a reactive strategy (incremental cost-effectiveness ratio of $146,494 per quality-adjusted life year), assuming a 40% of the wholesale price of IFX. The results were most sensitive to risk of flaring with a low IFX concentration and the cost of IFX. CONCLUSIONS Assuming 40% of the average wholesale acquisition cost of biologic therapies, proactive TDM for IFX is marginally cost-effective compared with a reactive TDM strategy. As the cost of infliximab decreases, a proactive monitoring strategy is more cost-effective.
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Affiliation(s)
- Diana M Negoescu
- Department of Industrial and Systems Engineering, University of Minnesota College of Science and Engineering, Minneapolis, MN
| | - Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Brooke Swanhorst
- Department of Industrial and Systems Engineering, University of Minnesota College of Science and Engineering, Minneapolis, MN
| | - Bonnie Baumgartner
- Department of Industrial and Systems Engineering, University of Minnesota College of Science and Engineering, Minneapolis, MN
| | - James P Campbell
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Mark T Osterman
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Disease, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam S Cheifetz
- Center for Inflammatory Bowel Disease, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Byron P Vaughn
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
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Leminen A, Pyykönen M, Tynkkynen J, Tykkyläinen M, Laatikainen T. Modeling patients' time, travel, and monitoring costs in anticoagulation management: societal savings achievable with the shift from warfarin to direct oral anticoagulants. BMC Health Serv Res 2019; 19:901. [PMID: 31775847 PMCID: PMC6882009 DOI: 10.1186/s12913-019-4711-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/05/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Anticoagulation therapy is used for atrial fibrillation (AF) patients for reducing the risk of cardioembolic complications such as stroke. The previously recommended anticoagulant, warfarin, has a narrow therapeutic window, and it requires regular laboratory monitoring, unlike direct oral anticoagulants (DOAC). From a societal perspective, it is important to measure time and travel costs associated with warfarin monitoring to better compare the total therapy costs of these two alternative forms of anticoagulation management. In this study we design a georeferenced cost model to investigate societal savings achievable with the shift from warfarin to DOACs in the study region of North Karelia in Eastern Finland. METHODS Individual-level patient data of 6519 AF patients was obtained from the regional patient database. Patients' geocoded home addresses and other GIS data were used to perform a network analysis for the optimal routes for warfarin monitoring visits. These measures of revealed accessibility were then used in the cost model to measure monetary time and travel costs in addition to direct healthcare costs of anticoagulation management. RESULTS The share of time and travel costs in warfarin monitoring is 26.6% of the total therapy costs in our study region. With current drug retail prices in Finland, the societal expense of anticoagulation management is only 2.6% higher with DOACs than in the baseline with warfarin. However, when 25% lower distributor's prices are used, the total societal cost decreases by 13.6% with DOACs. CONCLUSIONS Our results indicate that patients' time and travel costs critically increase the societal cost of warfarin therapy; and despite the higher price of DOACs, they are already cost-efficient alternatives to warfarin in anticoagulation management. In the future, the cost of AF complications should be included in the cost comparison between warfarin and DOACs. Our modeling approach applies to different geographical regions and to different healthcare processes requiring patient monitoring.
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Affiliation(s)
- Aapeli Leminen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Mikko Pyykönen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Juho Tynkkynen
- Faculty of Medicine and Health Technology, Tampere University, Kalevantie 4, 33100 Tampere, Finland
- Department of Radiology, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland
| | - Markku Tykkyläinen
- Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101 Joensuu, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland
- Joint municipal authority for North Karelia social and health services, Tikkamäentie 16, 80210 Joensuu, Finland
- Department of Public Health Solutions, National Institute for Health and Welfare (THL), P.O. Box 30, 00271 Helsinki, Finland
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Pyykönen M, Leminen A, Tynkkynen J, Tykkyläinen M, Laatikainen T. A geospatial model to determine the spatial cost-efficiency of anticoagulation drug therapy: Patients' perspective. Geospat Health 2019; 14. [PMID: 31724376 DOI: 10.4081/gh.2019.809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/05/2019] [Indexed: 06/10/2023]
Abstract
Most atrial fibrillation (AF) patients need anticoagulation management to reduce the risk of thromboembolic events and stroke. Currently, two major drug therapies are available: warfarin and direct oral anticoagulant (DOAC). This study examined the spatial costs of these therapies and derived the least-cost market areas for both therapies in the study area. The concepts of spatial costs and the principles of forming market areas were used as theoretical starting points, and the patients' travel, time-loss, and medication cost parameters combined with geographical information systems methods were incorporated into the geospatial model. Results showed that for AF patients who live near the international normalized ratio (INR) monitoring sample collection point and have less than 15 annual INR monitoring visits, warfarin therapy resulted in the lowest cost regardless of patient's travel mode and their assumed working or retirement status. If the AF patient needs more frequent INR monitoring visits or lives farther from the nearest sample collection point, DOAC would be the least costly option. The modelled results reveal the variety and importance of patients' cost of time loss and travel costs when a physician selects the appropriate anticoagulation therapy.
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Affiliation(s)
- Mikko Pyykönen
- Department of Geographical and Historical Studies, University of Eastern Finland, Joensuu.
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Heald A, Davies M, Stedman M, Livingston M, Lunt M, Fryer A, Gadsby R. Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes. BMJ Open 2019; 9:e028278. [PMID: 31494602 PMCID: PMC6731821 DOI: 10.1136/bmjopen-2018-028278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.
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Affiliation(s)
- Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | | | - Mark Livingston
- Clinical Biochemistry, Walsall Healthcare NHS Trust, Walsall, UK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Anthony Fryer
- Clinical Biochemistry, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
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12
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Bobade RA, Helmers RA, Jaeger TM, Odell LJ, Haas DA, Kaplan RS. Time-driven activity-based cost analysis for outpatient anticoagulation therapy: direct costs in a primary care setting with optimal performance. J Med Econ 2019; 22:471-477. [PMID: 30744455 DOI: 10.1080/13696998.2019.1582058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To determine how overall cost of anticoagulation therapy for warfarin compares with that of Novel Oral Anticoagulants (NOACs). Also, to demonstrate a scientific, comprehensive, and an analytical approach to estimate direct costs involved in monitoring and management of anticoagulation therapy for outpatients in an academic primary care clinic setting, post-initiation of therapy. METHODS A population-based cross-sectional study was conducted in conjunction with observations of patient care processes between August 2014 and January 2015. The study was conducted in an academic primary care outpatient setting at Mayo Clinic's warfarin anticoagulation clinic, Rochester, MN. The anticoagulation clinic serves patients 18 years of age or older in Warfarin therapy management, for any indication, after referral from the patient's primary care provider. The study included anticoagulation clinic enrollment data on a population of 5,526 patients. Time-Driven Activity-Based Costing (TDABC) technique was applied. Detailed process flow maps which showed process steps for all the anticoagulation program components and care continuum phases were created. Staff roles associated with each of the process steps were identified and displayed on the maps. Process times and costs were captured and analyzed. The main outcome was direct cost of monitoring and management of anticoagulation therapy, post-initiation of therapy. RESULTS The cost of warfarin management for patients who display unstable International Normalized Ratio (INR) is more than three times those who display stable INR over time. (Comparator to distinguish stability: Frequency of point-of-care visits needed by patients.) For complex anticoagulation patients, total cost of medication and monitoring for warfarin anticoagulation therapy is similar to that for NOACs. CONCLUSION Despite warfarin being significantly less expensive to purchase than NOACs, overall warfarin management incurs higher costs due to laboratory monitoring and provider time than NOACs. NOAC treatment, therefore, may not be more expensive than warfarin therapy management for complex anticoagulation patients.
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Affiliation(s)
- Rohit A Bobade
- a Surgical Specialties Division , Mayo Clinic Health System , La Crosse , WI , USA
| | - Richard A Helmers
- b Critical Care Medicine , College of Medicine , Mayo Clinic, Eau Claire , WI , USA
| | - Thomas M Jaeger
- c Community Internal Medicine , College of Medicine , Rochester , MN , USA
| | - Laura J Odell
- d Global Business Solutions , Mayo Clinic , Rochester , MN , USA
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Korjian S, Daaboul Y, Laliberté F, Zhao Q, Mehran R, Bode C, Halperin J, Verheugt FWA, Lip GYH, Cohen M, Peterson ED, Fox KAA, Gibson CM, Pinto DS. Cost Implications of Anticoagulation Strategies After Percutaneous Coronary Intervention Among Patients With Atrial Fibrillation (A PIONEER-AF PCI Analysis). Am J Cardiol 2019; 123:355-360. [PMID: 30502047 DOI: 10.1016/j.amjcard.2018.10.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022]
Abstract
The PIONEER AF-PCI trial demonstrated that in atrial fibrillation patients who underwent intracoronary stenting, either rivaroxaban 15 mg daily plus P2Y12 inhibitor monotherapy (Group 1) or 2.5 mg rivaroxaban twice daily plus dual antiplatelet therapy (DAPT) (Group 2) was associated with fewer recurrent hospitalizations, primarily for bleeding and cardiovascular events, compared with standard-of-care vitamin K antagonist and DAPT (Group 3). Associated costs are unknown. This study estimates costs associated with rivaroxaban strategies compared with vitamin K antagonist and DAPT. Medication costs were estimated using wholesale acquisition costs, medication discontinuation rates, and costs of monitoring. Using a large US healthcare claims database, the mean adjusted increase in 1-year cost of care for individuals with atrial fibrillation and percutaneous coronary intervention (PCI) rehospitalized for bleeding, cardiovascular, and other events was compared with those not rehospitalized. Using adjudicated rehospitalization rates from PIONEER AF-PCI, cost differences were estimated. Rates of rehospitalization for bleeding were 6.5%, 5.4%, 10.5%, and 20.3%, 20.3%, 28.4% for cardiovascular events in Groups 1, 2, and 3. Medication and monitoring costs were $3,942, $4,115, and $1,703. One-year costs for all recurrent hospitalization costs and/or patient for the groups were $24,535, $20,205, and $29,756. One-year cost increase associated with bleeding rehospitalizations and/or patient was $4,160, $3,212, and $6,876 and was $13,264, $11,545, and $17,220 for cardiovascular rehospitalizations and/or patient. Overall estimated cost per patient was $28,476, $24,320, and $31,458. Compared with warfarin, both rivaroxaban treatment strategies had higher medication costs, but these were more than accounted for by fewer hospitalizations.
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Affiliation(s)
- Serge Korjian
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts
| | | | | | - Qi Zhao
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Roxana Mehran
- The Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York
| | - Christoph Bode
- Department for Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Jonathan Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | | | - Marc Cohen
- The Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | | | - Keith A A Fox
- The Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts
| | - Duane S Pinto
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts.
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Bunniran S, Lee E, Kamble P, Suehs B, Franks B, Schwartz J, Thal G, Spalding J. Healthcare utilization and costs with fixed-source versus variable-source tacrolimus in patients receiving a kidney transplant. J Med Econ 2018; 21:1067-1074. [PMID: 30032686 DOI: 10.1080/13696998.2018.1503596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS Switching drug manufacturers in transplant patients may require an increased intensity of therapeutic monitoring, leading to additional healthcare visits, associated laboratory tests, and perhaps hospitalizations. As real-world studies examining the interchangeability of tacrolimus from different manufacturers are limited, the purpose of this study was to examine the healthcare resource utilization (HRU) and economic impact of tacrolimus-switching in kidney transplantation. MATERIALS AND METHODS This cross-sectional, retrospective study examined HRU and healthcare costs (HCCs) among patients with a kidney transplant who were prescribed tacrolimus from fixed-source (FS) vs variable-source (VS) manufacturers using claims data from the large US health plan Humana from October 1, 2012, to December 31, 2013. RESULTS Overall, 1,024 patients were identified (FS: n = 674, 66%; VS: n = 350, 34%). The number of therapeutic drug monitoring (TDM) events for the VS group was 13% greater than for the FS group after controlling for demographics, comorbidity score, and number of medications (incidence rate ratio = 1.13, p = .033). Adjusted total HCCs were 9% lower for VS (US$28,054 vs US$30,823, p = .045). In the unadjusted analysis, VS had greater emergency department (ED) utilization (45% vs 35%, p < .002). In the VS group, the mean (standard deviation [SD]) number of days from manufacturer switch to first outpatient visit was 23.8 (33.6), and the number of days (SD) to first TDM event was 43.6 (56.2). LIMITATIONS Study limitations include the lack of availability of many transplant-specific variables within the Humana database, potential errors/omissions in claims coding, and restriction of cross-sectional data examination to a 1-year period. CONCLUSIONS VS patients had greater TDM and lower total HCCs. Further research is warranted to understand the drivers of ED use among the VS group, and to determine factors associated with delayed TDM after regimen modification. Opportunities may exist to improve the quality of care for patients receiving immunosuppressant treatment with tacrolimus.
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Affiliation(s)
- Suvapun Bunniran
- a Comprehensive Health Insights , Humana Inc. , Louisville , KY , USA
| | - Edward Lee
- b Formerly Medical Affairs , Astellas Pharma Global Development, Inc. , Northbrook , IL , USA
| | - Pravin Kamble
- c Formerly Comprehensive Health Insights , Humana Inc. , Louisville , KY , USA
| | - Brandon Suehs
- a Comprehensive Health Insights , Humana Inc. , Louisville , KY , USA
| | - Billy Franks
- d Real-World Informatics , Astellas Pharma Global Development, Inc. , Leiden , Netherlands
| | - Jason Schwartz
- e Medical Affairs , Astellas Pharma Global Development, Inc. , Northbrook , IL , USA
| | - Gary Thal
- e Medical Affairs , Astellas Pharma Global Development, Inc. , Northbrook , IL , USA
| | - James Spalding
- e Medical Affairs , Astellas Pharma Global Development, Inc. , Northbrook , IL , USA
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15
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Seng JJB, Yong MHA, Peh ZX, Soong JL, Tan MH. Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore. Int J Clin Pharm 2018; 40:977-981. [PMID: 29948742 DOI: 10.1007/s11096-018-0670-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 05/31/2018] [Indexed: 11/25/2022]
Abstract
Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received ≥ 1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1-4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p > 0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.
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Affiliation(s)
| | - Mei Hui Amanda Yong
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Zi Xin Peh
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Jie Lin Soong
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Mooi Heong Tan
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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16
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Zhou FL, Ye F, Berhanu P, Gupta VE, Gupta RA, Sung J, Westerbacka J, Bailey TS, Blonde L. Real-world evidence concerning clinical and economic outcomes of switching to insulin glargine 300 units/mL vs other basal insulins in patients with type 2 diabetes using basal insulin. Diabetes Obes Metab 2018; 20:1293-1297. [PMID: 29272064 PMCID: PMC5947830 DOI: 10.1111/dom.13199] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022]
Abstract
This retrospective cohort study compared real-world clinical and healthcare-resource utilization (HCRU) data in patients with type 2 diabetes using basal insulin (BI) who switched to insulin glargine 300 units/mL (Gla-300) or another BI. Data from the Predictive Health Intelligence Environment database 12 months before (baseline) and 6 months after (follow-up) the switch date (index date, March 1, 2015 to May 31, 2016) included glycated haemoglobin A1c (HbA1c), hypoglycaemia, HCRU and associated costs. Baseline characteristics were balanced using propensity score matching. Change in HbA1c from baseline was similar in both matched cohorts (n = 1819 in each). Hypoglycaemia incidence and adjusted event rate were significantly lower with Gla-300. Patients switching to Gla-300 had a significantly lower incidence of HCRU related to hypoglycaemia. All-cause and diabetes-related hospitalization and emergency-department HCRU were also favourable for Gla-300. Lower HCRU translated to lower costs in patients using Gla-300. In this real-world study, switching to Gla-300 reduced the risk of hypoglycaemia in patients with type 2 diabetes when compared with those switching to another BI, resulting in less HCRU and potential savings of associated costs.
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Affiliation(s)
| | - Fen Ye
- SanofiBridgewaterNew Jersey
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17
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Verhoven SM, Groszek JJ, Fissell WH, Seegmiller A, Colby J, Patel P, Verstraete A, Shotwell M. Therapeutic drug monitoring of piperacillin and tazobactam by RP-HPLC of residual blood specimens. Clin Chim Acta 2018; 482:60-64. [PMID: 29596815 DOI: 10.1016/j.cca.2018.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sepsis is a common diagnosis in critical care with inpatient mortality rates up to 50%. Sepsis care is organized around source control, antibiotics, and supportive care. Drug disposition is deranged by changes in volume of distribution and regional blood flow, as well as multiple organ failure. Thus, assuring that each patient with sepsis attains pharmacokinetic targets is challenging. There is currently no commercially available FDA-approved assay to measure piperacillin-tazobactam, very commonly used as a beta-lactam/beta-lactamase inhibitor combination antibiotic in the intensive care unit (ICU). METHODS Samples were prepared by ultrafiltration of plasma collected in lithium heparin Vacutainers. Separation was achieved by gradient elution on a C-18 column followed by UV detection at 214 nm. The method is validated in residual blood samples allowing investigators to exploit a waste product to develop insight into beta-lactam pharmacokinetics in the ICU. RESULTS Accuracy and precision were within the 25% CLIA error standard for other antibiotic assays. Free piperacillin concentrations were also in good agreement with total piperacillin concentrations measured in the same plasma by an assay in clinical use outside the United States. CONCLUSION We describe a method for measuring piperacillin and tazobactam that meets clinical validation standards. Quick turnaround time and excellent accuracy on a low-cost platform make this method more than adequate for use as a routine therapeutic drug monitoring tool.
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Affiliation(s)
- Sylvia M Verhoven
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Joseph J Groszek
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, United States
| | - William H Fissell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Adam Seegmiller
- Pathology Microbiology and Immunonology, Vanderbilt University Medical Center, United States
| | - Jennifer Colby
- Pathology Microbiology and Immunonology, Vanderbilt University Medical Center, United States
| | - Pratish Patel
- Therapeutic Drug Monitoring/Antimicrobial Stewardship, Vanderbilt University Medical Center, United States
| | - Alain Verstraete
- Department of Clinical Chemistry Microbiology and Immunology, Ghent University Hospital, Belgium
| | - Matthew Shotwell
- Department of Biostatistic, Vanderbilt University Medical Center, United States; Department of Anesthesiology, Vanderbilt University Medical Center, United States
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Heald AH, Livingston M, Malipatil N, Becher M, Craig J, Stedman M, Fryer AA. Improving type 2 diabetes mellitus glycaemic outcomes is possible without spending more on medication: Lessons from the UK National Diabetes Audit. Diabetes Obes Metab 2018; 20:185-194. [PMID: 28730750 DOI: 10.1111/dom.13067] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
Abstract
AIMS To determine the factors at general practice level that relate to glycaemic control outcomes in people with type 2 diabetes (T2DM). METHODS Data were accessed from 4050 general practices (50% of total) covering 1.6 million patients with T2DM in the UK National Diabetes Audit 2013 to 2014 and 2014 to 2015. This audit reported characteristics, services and outcomes in the T2DM population, including percentage of patients who had total glycaemic control (TGC), defined as glycated haemoglobin (HbA1c) ≤7.5% (58 mmol/mol), and the percentage who were at higher glycaemic risk (HGR), defined as HbA1c >10% (86 mmol/mol); the respective figures were 67.2% and 6.2%. The medication data were examined in terms of annual defined daily doses (DDDs). Multivariate linear regression analysis was used to identify associations between DDD and patient and practice characteristics. RESULTS Over the period 2012/2013 to 2015/2016, patient numbers grew 4% annually and annual medication expenditure by 8%, but glycaemic control outcomes did not improve. The main findings were that practices with better outcomes: had a higher percentage of patients aged >65 years; provided more effective diabetes services (including case identification, care checks, patient education, percentage of patients with blood pressure and cholesterol under control and more patients with type 1 diabetes achieving target HbA1c levels); spent less overall on prescribing per patient with T2DM; and on average, prescribed fewer sulphonylureas, less insulin (for patients with T2DM), fewer glucagon-like peptide-1 agonists, more metformin, more dipeptidyl peptidase-4 inhibitors, and more blood glucose monitoring strips. Ethnicity and social disadvantage and levels of thiazolidinedione (glitazone) prescribing had no significant impact on outcomes. Sodium-glucose co-transporter-2 inhibitor use was too low for an effect to be observed in the period examined. CONCLUSIONS If all practices brought their service and medication to the level of the top decile practices, they could achieve 74.7% compared with the median of 67.3% of patients achieving TGC, showing an increase of 213 000 in patients achieving TGC, while reducing the number at HGR to 3.8% compared with 6.1%, benefiting 62 000 patients. This could have a major impact on the overall consequent healthcare costs of managing diabetes complications with their attendant mortality risks.
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Affiliation(s)
- Adrian H Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Nagaraj Malipatil
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Michal Becher
- Robotics and Control Systems, Technical University of Wroclaw, Wroclaw, Poland
| | | | | | - Anthony A Fryer
- Keele University School of Medicine, Newcastle-under-Lyme, UK
- Department of Clinical Biochemistry, University Hospital of North Staffordshire, Stoke-on-Trent, UK
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Kantito S, Saokaew S, Yamwong S, Vathesatogkit P, Katekao W, Sritara P, Chaiyakunapruk N. Cost-effectiveness analysis of patient self-testing therapy of oral anticoagulation. J Thromb Thrombolysis 2017; 45:281-290. [PMID: 29181693 DOI: 10.1007/s11239-017-1588-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient Self-testing (PST) could be an option for present anticoagulation therapy monitoring, but current evidence on its cost-effectiveness is limited. This study aims to estimate the cost-effectiveness of PST to other different care approaches for anticoagulation therapy in Thailand, a low-to-middle income country (LMIC). A Markov model was used to compare lifetime costs and quality-adjusted life years (QALYs) accrued to patients receiving warfarin through PST or either anticoagulation clinic (AC) or usual care (UC). The model was populated with relevant information from literature, network meta-analysis, and database analyses. Incremental cost-effectiveness ratios (ICERs) were presented as the year 2015 values. A base-case analysis was performed for patients at age 45-year-old. Sensitivity analyses including one-way and probabilistic sensitivity analyses (PSA) were constructed to determine the robustness of the findings. From societal perspective, PST increased QALY by 0.87 and costs by 112,461 THB compared with UC. Compared with AC, PST increased QALY by 0.161 and costs by 21,019 THB. The ICER with PST was 128,697 (3625 USD) and 130,493 THB (3676 USD) per QALY gained compared with UC and AC, respectively. The probability of PST being cost-effective is 74.1% and 51.9%, compared to UC and AC, respectively, in Thai context. Results were sensitive to the efficacy of PST, age and frequency of hospital visit or self-testing. This analysis suggested that PST is highly cost-effective compared with usual care and less cost-effective against anticoagulation clinic. Patient self-testing strategy appears to be economically valuable to include into healthcare system within the LMIC context.
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Affiliation(s)
- Sutat Kantito
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia
| | - Sukit Yamwong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prin Vathesatogkit
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisuit Katekao
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia.
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia.
- School of Pharmacy, University of Wisconsin, Madison, USA.
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Maguire R, Fox PA, McCann L, Miaskowski C, Kotronoulas G, Miller M, Furlong E, Ream E, Armes J, Patiraki E, Gaiger A, Berg GV, Flowerday A, Donnan P, McCrone P, Apostolidis K, Harris J, Katsaragakis S, Buick AR, Kearney N. The eSMART study protocol: a randomised controlled trial to evaluate electronic symptom management using the advanced symptom management system (ASyMS) remote technology for patients with cancer. BMJ Open 2017; 7:e015016. [PMID: 28592577 PMCID: PMC5734219 DOI: 10.1136/bmjopen-2016-015016] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology (eSMART) study is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised controlled trial of oncology patients. METHODS AND ANALYSIS A total of 1108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal or haematological cancer will be recruited from multiple sites across five European countries.Patients will be randomised (1:1) to the ASyMS intervention (intervention group) or to standard care currently available at each site (control group). Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient-reported outcome measures at enrolment, after each of their CTX cycles (up to a maximum of six cycles) and at 3, 6, 9 and 12 months after completion of their sixth cycle of CTX. Outcomes that will be assessed include symptom burden (primary outcome), quality of life, supportive care needs, anxiety, self-care self-efficacy, work limitations and cost effectiveness and, from a health professional perspective, changes in clinical practice (secondary outcomes). ETHICS AND DISSEMINATION Ethical approval will be obtained prior to the implementation of all major study amendments. Applications will be submitted to all of the ethics committees that granted initial approval.eSMART received approval from the relevant ethics committees at all of the clinical sites across the five participating countries. In collaboration with the European Cancer Patient Coalition (ECPC), the trial results will be disseminated through publications in scientific journals, presentations at international conferences, and postings on the eSMART website and other relevant clinician and consumer websites; establishment of an eSMART website (www.esmartproject.eu) with publicly accessible general information; creation of an eSMART Twitter Handle, and production of a toolkit for implementing/utilising the ASyMS technology in a variety of clinical practices and other transferable health care contexts. TRIAL REGISTRATION NUMBER NCT02356081.
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Affiliation(s)
- Roma Maguire
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
| | - Patricia A Fox
- UCD School of Nursing, Midwifery and Health Systems, Health Sciences Centre, Belfield, Dublin, Ireland
| | - Lisa McCann
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, California, USA
| | - Grigorios Kotronoulas
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
| | - Morven Miller
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
| | - Eileen Furlong
- UCD School of Nursing, Midwifery and Health Systems, Health Sciences Centre, Belfield, Dublin, Ireland
| | - Emma Ream
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
| | - Jo Armes
- Florence Nightingale Faculty of Nursing & Midwifery, King’s College London, James Clerk Maxwell Building, England, UK
| | - Elisabeth Patiraki
- National and Kapodistrian University of Athens, Papadiamantopoulou, Goudi, Athens, Greece
| | - Alexander Gaiger
- Medical University Vienna Comprehensive Cancer Center, Spitalgasse, Austria
| | - Geir V Berg
- Innlandet Hospital Trust Lillehammer and Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
| | | | - Peter Donnan
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Dundee, Scotland
| | - Paul McCrone
- King’s College London, David Goldberg Centre, Denmark Hill, London, UK
| | | | - Jenny Harris
- Florence Nightingale Faculty of Nursing & Midwifery, King’s College London, James Clerk Maxwell Building, England, UK
| | - Stylianos Katsaragakis
- National and Kapodistrian University of Athens, Papadiamantopoulou, Goudi, Athens, Greece
| | - Alison R Buick
- UCD School of Nursing, Midwifery and Health Systems, Health Sciences Centre, Belfield, Dublin, Ireland
| | - Nora Kearney
- University of Surrey, Faculty of Health and Medical Sciences, Duke of Kent Building, Surrey, Guildford, UK
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Caniglia EC, Cain LE, Sabin CA, Robins JM, Logan R, Abgrall S, Mugavero MJ, Hernández-Díaz S, Meyer L, Seng R, Drozd DR, Seage GR, Bonnet F, Dabis F, Moore RD, Reiss P, van Sighem A, Mathews WC, Del Amo J, Moreno S, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Napravnik S, Jose S, Phillips A, Justice AC, Tate JP, Gill J, Pacheco A, Veloso VG, Bucher HC, Egger M, Furrer H, Porter K, Touloumi G, Crane H, Miro JM, Sterne JA, Costagliola D, Saag M, Hernán MA. Comparison of dynamic monitoring strategies based on CD4 cell counts in virally suppressed, HIV-positive individuals on combination antiretroviral therapy in high-income countries: a prospective, observational study. Lancet HIV 2017; 4:e251-e259. [PMID: 28411091 PMCID: PMC5492888 DOI: 10.1016/s2352-3018(17)30043-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/14/2017] [Accepted: 01/19/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Clinical guidelines vary with respect to the optimal monitoring frequency of HIV-positive individuals. We compared dynamic monitoring strategies based on time-varying CD4 cell counts in virologically suppressed HIV-positive individuals. METHODS In this observational study, we used data from prospective studies of HIV-positive individuals in Europe (France, Greece, the Netherlands, Spain, Switzerland, and the UK) and North and South America (Brazil, Canada, and the USA) in The HIV-CAUSAL Collaboration and The Centers for AIDS Research Network of Integrated Clinical Systems. We compared three monitoring strategies that differ in the threshold used to measure CD4 cell count and HIV RNA viral load every 3-6 months (when below the threshold) or every 9-12 months (when above the threshold). The strategies were defined by the threshold CD4 counts of 200 cells per μL, 350 cells per μL, and 500 cells per μL. Using inverse probability weighting to adjust for baseline and time-varying confounders, we estimated hazard ratios (HRs) of death and of AIDS-defining illness or death, risk ratios of virological failure, and mean differences in CD4 cell count. FINDINGS 47 635 individuals initiated an antiretroviral therapy regimen between Jan 1, 2000, and Jan 9, 2015, and met the eligibility criteria for inclusion in our study. During follow-up, CD4 cell count was measured on average every 4·0 months and viral load every 3·8 months. 464 individuals died (107 in threshold 200 strategy, 157 in threshold 350, and 200 in threshold 500) and 1091 had AIDS-defining illnesses or died (267 in threshold 200 strategy, 365 in threshold 350, and 459 in threshold 500). Compared with threshold 500, the mortality HR was 1·05 (95% CI 0·86-1·29) for threshold 200 and 1·02 (0·91·1·14) for threshold 350. Corresponding estimates for death or AIDS-defining illness were 1·08 (0·95-1·22) for threshold 200 and 1·03 (0·96-1·12) for threshold 350. Compared with threshold 500, the 24 month risk ratios of virological failure (viral load more than 200 copies per mL) were 2·01 (1·17-3·43) for threshold 200 and 1·24 (0·89-1·73) for threshold 350, and 24 month mean CD4 cell count differences were 0·4 (-25·5 to 26·3) cells per μL for threshold 200 and -3·5 (-16·0 to 8·9) cells per μL for threshold 350. INTERPRETATION Decreasing monitoring to annually when CD4 count is higher than 200 cells per μL compared with higher than 500 cells per μL does not worsen the short-term clinical and immunological outcomes of virally suppressed HIV-positive individuals. However, more frequent virological monitoring might be necessary to reduce the risk of virological failure. Further follow-up studies are needed to establish the long-term safety of these strategies. FUNDING National Institutes of Health.
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Affiliation(s)
- Ellen C Caniglia
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Lauren E Cain
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - James M Robins
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Roger Logan
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Sophie Abgrall
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France; Assistance Publique-Hopitaux de Paris (AP-HP), Hopital Antoine Béclère, Service de Médecine Interne, Clamart, France
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; UAB Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Laurence Meyer
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Remonie Seng
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Daniel R Drozd
- School of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - George R Seage
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Fabrice Bonnet
- Institut de Santé Publique, d'Epidémiologie et de Développement, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Francois Dabis
- INSERM U897, Centre INSERM Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, Netherlands; Academic Medical Center, Department of Global Health and Division of Infectious Diseases, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | | | - Julia Del Amo
- National Centre of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Santiago Moreno
- Ramón y Cajal Hospital, IRYCIS, Madrid, Spain; University of Alcalá de Henares, Madrid, Spain
| | - Steven G Deeks
- Positive Health Program, San Francisco General Hospital, San Francisco, CA, USA
| | - Roberto Muga
- Servei de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Elena Ferrer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat, Barcelona, Spain
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amy C Justice
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Janet P Tate
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - John Gill
- Southern Alberta HIV Clinic, University of Calgary, Calgary, AB, Canada
| | - Antonio Pacheco
- Programa de Computação Científica, FIOCRUZ, Rio de Janeiro, Brazil
| | | | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Heidi Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jose M Miro
- Infectious Diseases, Hospital Clinic-IDIBAPS, Barcelona, Spain
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Michael Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Miguel A Hernán
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
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Affiliation(s)
- Luigi F Meneghini
- 1 Division of Endocrinology, UT Southwestern Medical Center , Dallas, Texas
- 2 Global Diabetes Program, Parkland Health & Hospital System , Dallas, Texas
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Jani M, Gavan S, Chinoy H, Dixon WG, Harrison B, Moran A, Barton A, Payne K. A microcosting study of immunogenicity and tumour necrosis factor alpha inhibitor drug level tests for therapeutic drug monitoring in clinical practice. Rheumatology (Oxford) 2016; 55:2131-2137. [PMID: 27576368 PMCID: PMC5144665 DOI: 10.1093/rheumatology/kew292] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 06/29/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To identify and quantify resource required and associated costs for implementing TNF-α inhibitor (TNFi) drug level and anti-drug antibody (ADAb) tests in UK rheumatology practice. METHODS A microcosting study, assuming the UK National Health Service perspective, identified the direct medical costs associated with providing TNFi drug level and ADAb testing in clinical practice. Resource use and costs per patient were identified via four stages: identification of a patient pathway with resource implications; estimation of the resources required; identification of the cost per unit of resource (2015 prices); and calculation of the total costs per patient. Univariate and multiway sensitivity analyses were performed using the variation in resource use and unit costs. RESULTS Total costs for TNFi drug level and concurrent ADAb testing, assessed using ELISAs on trough serum levels, were £152.52/patient (range: £147.68-159.24) if 40 patient samples were tested simultaneously. For the base-case analysis, the pre-testing phase incurred the highest costs, which included booking an additional appointment to acquire trough blood samples. The additional appointment was the key driver of costs per patient (67% of the total cost), and labour accounted for 10% and consumables 23% of the total costs. Performing ELISAs once per patient (rather than in duplicate) reduced the total costs to £133.78/patient. CONCLUSION This microcosting study is the first assessing the cost of TNFi drug level and ADAb testing. The results could be used in subsequent cost-effectiveness analyses of TNFi pharmacological tests to target treatments and inform future policy recommendations.
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Affiliation(s)
- Meghna Jani
- Centre for Musculoskeletal Research
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair
| | - Sean Gavan
- Manchester Centre for Health Economics, Institute of Population Health, Manchester Academic Health Science Centre University of Manchester
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
| | - Hector Chinoy
- Centre for Musculoskeletal Research
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - William G Dixon
- Centre for Musculoskeletal Research
- Arthritis Research UK Centre for Epidemiology, Institute of Inflammation and Repair
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | - Beverley Harrison
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford
| | | | - Anne Barton
- Centre for Musculoskeletal Research
- National Institute of Health Research Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust Manchester Academic Health Science Centre, Manchester
- Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Institute of Population Health, Manchester Academic Health Science Centre University of Manchester,
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Petryszyn P, Wiela-Hojeńska A. ECONOMIC ISSUES IN THERAPEUTIC DRUG MONITORING. Acta Pol Pharm 2016; 73:599-604. [PMID: 27476276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The fact that resources for health care are limited has been found as a rationale for the development of pharmacoeconomics. Pharmacoeconomic analysis identifies, measures and compares the costs and the economic, clinical and humanistic outcomes of diseases, drug therapies and programmes directed to these diseases. As health care expenditures have escalated over the past decades, the number of its applications has increased. Taking into consideration outcome and economic issues and establishing their mutual relationship helps proper resource allocation. In the case of some effective and toxic drugs therapeutic drug monitoring has been proven to allow obtaining the desired clinical effects safely and thus to improve outcome. However, it requires the presence of clinical pharmacology or clinical pharmacy service within a hospital, which in turn is associated with some additional costs. This review sums up the results of pharmacoeconomic studies relevant to the use of therapeutic drug monitoring in case of the medicines for which it has been commonly performed so far.
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Deng S, Kiscoan M, Frazee C, Abdel-Rahman S, Dalal J, Garg U. A Simple Liquid Chromatography Tandem Mass Spectrometry Method for Quantitation of Plasma Busulfan. Methods Mol Biol 2016; 1383:79-87. [PMID: 26660176 DOI: 10.1007/978-1-4939-3252-8_9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Busulfan is an alkylating agent widely used in the ablation of bone marrow cells before hematopoietic stem cell transplant. Due to large intraindividual and interindividual variations, and narrow therapeutic window, therapeutic drug monitoring of busulfan is warranted. A quick and reliable HPLC-MS/MS method was developed for the assay of plasma busulfan. HPLC involved C18 column, and MS/MS was used in electrospray ionization (ESI) positive mode. Quantitation and identification of busulfan was made using various multiple reactions monitoring (MRMs). Isotopic labeled busulfan-d8 was used as the internal standard. The method is linear from 50 to 2500 ng/mL and has with-in run and between-run imprecision of <10 %.
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Affiliation(s)
- Shuang Deng
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, USA
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Michael Kiscoan
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, USA
| | - Clint Frazee
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, USA
| | - Susan Abdel-Rahman
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Jignesh Dalal
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Uttam Garg
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, USA.
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Larsson I, Fridlund B, Arvidsson B, Teleman A, Svedberg P, Bergman S. A nurse-led rheumatology clinic versus rheumatologist-led clinic in monitoring of patients with chronic inflammatory arthritis undergoing biological therapy: a cost comparison study in a randomised controlled trial. BMC Musculoskelet Disord 2015; 16:354. [PMID: 26573936 PMCID: PMC4647492 DOI: 10.1186/s12891-015-0817-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 11/13/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Recommendations for rheumatology nursing management of chronic inflammatory arthritis (CIA) from European League Against Rheumatism (EULAR) states that nurses should take part in the monitoring patients' disease and therapy in order to achieve cost savings. The aim of the study was to compare the costs of rheumatology care between a nurse-led rheumatology clinic (NLC), based on person-centred care (PCC), versus a rheumatologist-led clinic (RLC), in monitoring of patients with CIA undergoing biological therapy. METHODS Patients with CIA undergoing biological therapy (n = 107) and a Disease Activity Score of 28 ≤ 3.2 were randomised to follow-up by either NLC or RLC. All patients met the rheumatologist at inclusion and after 12 months. In the intervention one of two annual monitoring visits in an RLC was replaced by a visit to an NLC. The primary outcome was total annual cost of rheumatology care. RESULTS A total of 97 patients completed the RCT at the 12 month follow-up. Replacing one of the two annual rheumatologist monitoring visits by a nurse-led monitoring visit, resulted in no additional contacts to the rheumatology clinic, but rather a decrease in the use of resources and a reduction of costs. The total annual rheumatology care costs including fixed monitoring, variable monitoring, rehabilitation, specialist consultations, radiography, and pharmacological therapy, generated € 14107.7 per patient in the NLC compared with € 16274.9 in the RCL (p = 0.004), giving a € 2167.2 (13 %) lower annual cost for the NLC. CONCLUSIONS Patients with CIA and low disease activity or in remission undergoing biological therapy can be monitored with a reduced resource use and at a lower annual cost by an NLC, based on PCC with no difference in clinical outcomes. This could free resources for more intensive monitoring of patients early in the disease or patients with high disease activity. TRIAL REGISTRATION The trial is registered as a clinical trial at the ClinicalTrials.gov (NCT01071447). Registration date: October 8, 2009.
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Affiliation(s)
- Ingrid Larsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden.
- Spenshult Research and Development Centre, Halmstad, Sweden.
| | - Bengt Fridlund
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Barbro Arvidsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | | | - Petra Svedberg
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | - Stefan Bergman
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Nair SC, Welsing PMJ, Jacobs JWG, van Laar JM, Rensen WHJ, Ardine de Wit G, Bijlsma JWJ, Lafeber FPJG. Economic evaluation of a tight-control treatment strategy using an imaging device (handscan) for monitoring joint inflammation in early rheumatoid arthritis. Clin Exp Rheumatol 2015; 33:831-838. [PMID: 26343274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of a tight-control treatment strategy using the handscan (TCHS) compared to using only clinical assessments (TC) and compared to a general non-tight-control treatment strategy (usual care; UC) in early rheumatoid arthritis (RA). METHODS Data from 299 early RA patients from the CAMERA trial were used. Clinical outcomes were extrapolated to Quality Adjusted Life Years (QALYs) and costs using a Markov model. Costs and QALYs were compared between the TC and UC treatment strategy arm of the CAMERA trial and a simulated tight-control treatment strategy using the handscan (TCHS). Incremental Cost-Effectiveness Ratios (ICERs) were calculated and several scenario analyses performed. All analyses were performed probabilistically to obtain confidence intervals and costs-effectiveness planes and acceptability curves. RESULTS In TCHS, €4,660 (95% CI -€11,516 to €2,045) was saved and 0.06 (95% CI 0.01 to 0.11) QALYs were gained when compared to UC, with an ICER of €77,670 saved per QALY gained. Ninety-one percent (91%) of simulations resulted in less costs and more QALYs. TCHS resulted in comparable costs or even limited savings €642 (95% CI -€6,903 to €5,601)) and comparable QALYs to TC. In all scenario analyses, TCHS and TC were found to be cost effective as compared to UC. CONCLUSIONS A tight-control treatment strategy is highly cost-effective compared to a non-tight-control approach in early RA. Using the handscan as a monitoring device might facilitate implementation of tight-control treatment strategy at comparable costs and with comparable effects. This approach should be investigated further.
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Affiliation(s)
- S C Nair
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - P M J Welsing
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - J W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht; and Amsterdam Rheumatology and Immunology Center (ARC), AMC Amsterdam, The Netherlands
| | - F P J G Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Simpson SH, Lier DA, Majumdar SR, Tsuyuki RT, Lewanczuk RZ, Spooner R, Johnson JA. Cost-effectiveness analysis of adding pharmacists to primary care teams to reduce cardiovascular risk in patients with Type 2 diabetes: results from a randomized controlled trial. Diabet Med 2015; 32:899-906. [PMID: 25594919 DOI: 10.1111/dme.12692] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Adding pharmacists to primary care teams significantly improved blood pressure control and reduced predicted 10-year cardiovascular risk in patients with Type 2 diabetes. This pre-specified sub-study evaluated the economic implications of this cardiovascular risk reduction strategy. METHODS One-year outcomes and healthcare utilization data from the trial were used to determine cost-effectiveness from the public payer perspective. Costs were expressed in 2014 Canadian dollars and effectiveness was based on annualized risk of cardiovascular events derived from the UKPDS Risk Engine. RESULTS The 123 evaluable trial patients included in this analysis had a mean age of 62 ( ± 11) years, 38% were men, and mean diabetes duration was 6 ( ± 7) years. Pharmacists provided 3.0 ( ± 1.9) hours of additional service to each intervention patient, which cost $226 ( ± $1143) per patient. The overall one-year per-patient costs for healthcare utilization were $190 lower in the intervention group compared with usual care [95% confidence interval (CI): -$1040, $668). Intervention patients had a significant 0.3% greater reduction in the annualized risk of a cardiovascular event (95% CI: 0.08%, 0.6%) compared with usual care. In the cost-effectiveness analysis, the intervention dominated usual care in 66% of 10,000 bootstrap replications. At a societal willingness-to-pay of $4000 per 1% reduction in annual cardiovascular risk, the probability that the intervention was cost-effective compared with usual care reached 95%. A sensitivity analysis using multiple imputation to replace missing data produced similar results. CONCLUSIONS Within a randomized trial, adding pharmacists to primary care teams was a cost-effective strategy for reducing cardiovascular risk in patients with Type 2 diabetes. In most circumstances, this intervention may also be cost saving.
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Affiliation(s)
- S H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - D A Lier
- Institute of Health Economics, Edmonton, Canada
| | - S R Majumdar
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
- Institute of Health Economics, Edmonton, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R T Tsuyuki
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R Z Lewanczuk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R Spooner
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - J A Johnson
- Institute of Health Economics, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
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Abohelaika S, Kamali F, Avery P, Robinson B, Kesteven P, Wynne H. Anticoagulation control and cost of monitoring of older patients on chronic warfarin therapy in three settings in North East England. Age Ageing 2014; 43:708-11. [PMID: 24947831 DOI: 10.1093/ageing/afu074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND novel oral anticoagulants may be particularly cost-effective when INR control (TTR) with warfarin is poor or monitoring difficult. SETTING the Newcastle upon Tyne monitoring service, set in hospital or general practice and a domiciliary-based service for housebound patients. OBJECTIVES to examine anticoagulation stability and costs of monitoring. SUBJECTS three hundred and twenty-six atrial fibrillation patients, 75 years and over, with target INR of two to three, accessing hospital (n = 100), general practice (n = 122) and domiciliary (n = 104) service. METHODS age, co-morbidities, length of warfarin treatment, medications, INR values and dose changes from January to December 2011 were recorded, and costs analysed. RESULTS home-monitored patients had taken warfarin for longer, mean 5.2 years, than hospital (3.7) or general practice (3.1) patients. Age and total number of drugs prescribed chronically were negatively related to TTR. INR measurements and dose changes were negatively associated with the duration of treatment, positively correlated with co-morbidities. The mean TTR was 78% in hospital, 71% in general practice and 68% in domiciliary monitored patients. INR was monitored more often in hospital and domiciliary groups than in general practice and more dose changes occurred in the domiciliary group than in others. Costs of warfarin and monitoring were £128 per patient per year for hospital, £126 for general practice and £222 for domiciliary patients. CONCLUSIONS further exploration of the clinical effectiveness of novel anticoagulants in dependent patients is warranted to determine to what extent trial outcomes so far achieved in a fitter elderly population are influenced by the chronic co-morbidities of old age.
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Affiliation(s)
- Salah Abohelaika
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Farhad Kamali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Peter Avery
- School of Mathematics and Statistics, Newcastle University, UK
| | - Brian Robinson
- Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Patrick Kesteven
- Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hilary Wynne
- Newcastle upon Tyne Hospitals NHS Foundation Trust- Care of the Older People's Medicine, Freeman Hospital, Freeman Road, Newcastle upon Tyne NE7 7DN, UK
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Walsh C, Murphy A, Kirby A, Vaughan C. Retrospective costing of warfarin. Ir Med J 2014; 107:133-135. [PMID: 24908854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In Ireland, there are four anticoagulants available for prescribing to patients with atrial fibrillation for stroke prevention. A key feature of the three most recent anticoagulants is that monitoring is redundant. Despite this, there is continued prescribing of the incumbent anticoagulant, warfarin, which requires monitoring. Lack of information regarding the cost of monitoring, and the extra burden it places on health budgets and patients, motivated this costing study. Using micro costing, the costs of warfarin treatment (including monitoring) was disaggregated and isolated from both the patients' and health care provider's perspectives in a Cork hospital. Costs to the health care provider per patient per clinic visited were 21.57 Euros. Patient costs incurred per patient per clinic were 48.50 Euros. Thus, the total costs per patient per visit were 70.07 Euros. This result reveals that while the pharmaceutical cost of warfarin is low; it is not an inexpensive therapy when monitoring costs are considered.
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Spence D. Bad medicine: monitoring patients' drugs. BMJ 2013; 347:f5779. [PMID: 24065433 DOI: 10.1136/bmj.f5779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Xie YM, Wang X, Wang N, Chang YP. [Technical specifications for post-marketing pharmacoeconomic evaluation of Chinese medicine (draft version for comments)]. Zhongguo Zhong Yao Za Zhi 2013; 38:2925-2929. [PMID: 24471305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Pharmacoeconomics is an important part of the post-marketing evaluation of Chinese medicine, post-marketing pharmacoeconomic evaluation can better reflect the clinical and market value of Chinese medicine, the purpose of establishing the technical specifications for pharmacoeconomic evaluation is to make the evaluation process and results regarding Chinese patent medicines more scientific and fair. Every country's technical specifications for pharmacoeconomic evaluation act as reference guidelines, we have already drawn up the technical specifications which take into account the special characteristics of Chinese medicine; these are in preparation for post-marketing pharmacoeconomic evaluation Chinese medicine.
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Affiliation(s)
- Yan-Ming Xie
- Institute of Basic Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing 100875, China
| | - Xin Wang
- Institute of Basic Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing 100875, China
| | - Nuo Wang
- Beijing Normal University, Beijing 100875, China
| | - Yan-Peng Chang
- Institute of Basic Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing 100875, China
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Fleury A, Garcia E, Hernández M, Carrillo R, Govezensky T, Fragoso G, Sciutto E, Harrison LJS, Parkhouse RME. Neurocysticercosis: HP10 antigen detection is useful for the follow-up of the severe patients. PLoS Negl Trop Dis 2013; 7:e2096. [PMID: 23505587 PMCID: PMC3591315 DOI: 10.1371/journal.pntd.0002096] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/23/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The most severe clinical form of neurocysticercosis (NC) occurs when cysticerci are located in the subarachnoid space at the base of the brain (SaB). The diagnosis, monitoring and treatment of NC-SaB, constitutes a severe clinical challenge. Herein we evaluate the potential of the HP10 antigen detection enzyme-linked immunosorbent assay (HP10 Ag-ELISA) in the long term follow-up of NC-SaB cases. Assay performance was compared with that of Magnetic Resonance Imaging (MRI). In addition, the robustness of the HP10 Ag-ELISA was evaluated independently at two different institutions. METHODOLOGY/PRINCIPAL FINDINGS A double-blind prospective cohort trial was conducted involving 38 NC-SaB cases and a total of 108 paired serum and cerebrospinal fluid (CSF) samples taken at intervals of 4 to 8 months for up to 43 months. At each medical visit, results of sera and CSF HP10 Ag-ELISA and MRI obtained at last visit were compared and their accuracy was evaluated retrospectively, considering radiological evolution between appointments. In the long-term follow-up study, HP10 Ag-ELISA had a better agreement than MRI with retrospective radiological evaluation. High reproducibility of HP10 Ag-ELISA between laboratories was also demonstrated. CONCLUSIONS Results reported in this study establish for the first time the usefulness of the comparatively low cost HP10 Ag-ELISA for long term follow-up of NC-SaB patients.
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Affiliation(s)
- Agnès Fleury
- Unidad Periférica, Instituto de Investigaciones Biomédicas, UNAM / Instituto Nacional de Neurología y Neurocirugía, Colonia la Fama, Delegación Tlalpan, México DF, México.
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Finocchario-Kessler S, Catley D, Thomson D, Bradley-Ewing A, Berkley-Patton J, Goggin K. Patient communication tools to enhance ART adherence counseling in low and high resource settings. Patient Educ Couns 2012; 89:163-170. [PMID: 22575433 PMCID: PMC3462269 DOI: 10.1016/j.pec.2012.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 01/03/2012] [Accepted: 03/31/2012] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Few articles have examined specific counseling tools used to increase antiretroviral therapy (ART) adherence. We present communication tools used in the context of Project MOTIV8, a randomized clinical trial. METHODS We developed, piloted, and evaluated pictorial images to communicate the importance of consistent dose timing and the concept of drug resistance. Electronic drug monitoring (EDM) review was also used to provide visual feedback and facilitate problem solving discussions. Adherence knowledge of all participants (n=204) was assessed at baseline and 48 weeks. Participant satisfaction with counseling was also assessed. RESULTS Adherence knowledge did not differ at baseline, however, at 48 weeks, intervention participants demonstrated significantly increased knowledge compared to controls F(1, 172)=10.76, p=0.001 (12.4% increase among intervention participants and 1.8% decrease among controls). Counselors reported that the tools were well-received, and 80% of participants felt the counseling helped them adhere to their medications. CONCLUSIONS Counseling tools were both positively received and effective in increasing ART adherence knowledge among a diverse population. PRACTICE IMPLICATIONS While developed for research, these counseling tools can be implemented into clinical practice to help patients; particularly those with lower levels of education or limited abstract thinking skills to understand medical concepts related to ART adherence.
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Dyer C. Test based on natural processes cannot be patented, rules US court. BMJ 2012; 344:e2290. [PMID: 22446741 DOI: 10.1136/bmj.e2290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND Patients being managed on warfarin make frequent or regular visits to anticoagulation monitoring appointments. International studies have evaluated transportation cost and associated time related to anticoagulation clinic visits. To our knowledge, no studies have evaluated the cost of transportation to such clinic visits in the United States. OBJECTIVE To describe the methods of transportation and estimate the average total cost of transportation to and from an anticoagulation clinic in an urban setting. METHODS We prospectively conducted a survey of patients treated at the Harper Anticoagulation Clinic located in Detroit, Michigan, during November 2010. The survey was given to patients while waiting at their regularly scheduled clinic appointments and included questions regarding mode of transportation, distance traveled in miles, parking payment, and time missed from work for clinic appointments. The mean distance traveled was translated into cost assuming 50 cents per mile based on 2010 estimates by the Internal Revenue Service. RESULTS Sixty patients responded to the 11-item survey; response rates for individual items varied because participants were instructed to skip questions that did not pertain to them. Of the 47 participants responding to demographic questions, 70.2% were female, and 46.8% were older than 60 years. Transportation by private vehicle (80.0%), either driven by patients (41.7%) or someone else (38.3%), was the most common method reported. Use of private automobile translated into a cost of $11.19 per round trip. Other means of transportation identified include a ride from a medical transportation service (10.0%), bus (5.0%), walking (3.3%), and taxi (1.7%). The mean (SD) distance traveled to the clinic for all methods of transportation was 8.34 (7.7) miles. We estimated the average cost of round-trip transportation to be $10.78 weighted for all transportation modes. This is a direct nonmedical cost that is paid for by most patients out of pocket. However, 9 of 44 (20.5%) responded that their insurance plans provided at least some coverage for their rides to the anticoagulation clinic. Most participants stated that they did not take any time off work for clinic visits (88%) primarily because a large proportion of the study population was unemployed or retired. CONCLUSION The round-trip cost of transportation to an anticoagulation clinic in an urban setting in the United States may translate into a substantial expense, ranging from weekly appointments ($560 annually) to once monthly appointments ($130 annually).
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Affiliation(s)
- Jamie M. Hwang
- BCPS, Department of Pharmacy Practice, Wayne State University, 259 Mack Ave., Ste. 2190, Detroit, MI 48201, USA.
| | - Jennifer Clemente
- BCPS, Department of Pharmacy Practice, Wayne State University, 259 Mack Ave., Ste. 2190, Detroit, MI 48201, USA.
| | - Krishna P. Sharma
- BCPS, Department of Pharmacy Practice, Wayne State University, 259 Mack Ave., Ste. 2190, Detroit, MI 48201, USA.
| | - Thomas N. Taylor
- BCPS, Department of Pharmacy Practice, Wayne State University, 259 Mack Ave., Ste. 2190, Detroit, MI 48201, USA.
| | - Candice L. Garwood
- BCPS, Department of Pharmacy Practice, Wayne State University, 259 Mack Ave., Ste. 2190, Detroit, MI 48201, USA.
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Zeng YC, Xiao YP, Xue M. Exemestane for breast-cancer prevention. N Engl J Med 2011; 365:1056; author reply 1057-8. [PMID: 21916644 DOI: 10.1056/nejmc1108287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rosenthal ES, Bashan E, Herman WH, Hodish I. The effort required to achieve and maintain optimal glycemic control. J Diabetes Complications 2011; 25:283-8. [PMID: 21367626 DOI: 10.1016/j.jdiacomp.2011.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 01/18/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Insulin therapy is most effective when dosage is frequently adjusted. We sought to evaluate the effort required to maintain A1C below 7% once attained in older patients with type 2 diabetes. METHODS A total of 2380 insulin dosage adjustment episodes were analyzed for their intensity and frequency. The data were divided into an "induction period" (n=608), defined as the time before subjects' A1C dropped below 7% for the first time, and a "maintenance period" (n=1772), defined as the remaining study period. The data originated from a published study and included 26 older subjects with suboptimally controlled type 2 diabetes treated for a year with intensive insulin therapy. To achieve therapy goals, the study team contacted the subjects once every few weeks, reviewed records and optimized the insulin dosage. RESULTS During both the induction and maintenance periods, insulin dosage (both long-acting and fast-acting) was adjusted by more than 20%. Maintaining A1C below 7% required dosage adjustments every 2.7(±1.0) weeks, averaging 11.4% (±4.0) in 2.0 (±0.3) different components of insulin dosage (i.e., two of either long-acting or short-acting for breakfast, lunch or dinner) per contact. CONCLUSIONS Considerable effort was required to maintain optimal A1C levels in older patients with type 2 diabetes. Since the full benefit of insulin therapy is attained only when multiple components of insulin dosage are frequently adjusted and given the growing shortage of care providers' availability, innovative approaches are needed to empower patients to safely make their own insulin adjustments.
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Affiliation(s)
- Elyse S Rosenthal
- University of Michigan, College of Literature, Arts & Sciences, Ann Arbor, MI, USA
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Spence MM, Polzin JK, Weisberger CL, Martin JP, Rho JP, Willick GH. Evaluation of a pharmacist-managed amiodarone monitoring program. J Manag Care Pharm 2011; 17:513-22. [PMID: 21870892 PMCID: PMC10437408 DOI: 10.18553/jmcp.2011.17.7.513] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Because of the potential for serious adverse effects, patients treated with amiodarone must be carefully screened and routinely monitored for potential liver, thyroid, and pulmonary toxicity. However, laboratory and pulmonary monitoring rates have been found to be substantially lower than recommended in guidelines, including those of the North American Society of Pacing and Electrophysiology (NASPE, 2007). OBJECTIVE To (a) assess rates of laboratory monitoring of liver, thyroid, and pulmonary function and adverse events in a pharmacist-managed amiodarone monitoring program compared with usual care in an integrated health care system and (b) estimate return on investment (ROI) from this intervention. METHODS This retrospective cohort study used clinic and enrollment data to identify those patients in the pharmacist-managed program and usual care who received at least 100 days of amiodarone therapy with the first prescription for amiodarone (index) from June 1, 2007, through May 31, 2009 (index date). Laboratory test monitoring was recorded at baseline (up to 6 months before the index date), from 1-6 months after the index date, 7-12 months after the index date, and at any time during the year (months 1-12). Alanine aminotransferase (ALT) was evaluated for liver function. Thyroid-stimulating hormone (TSH) and, for patients with abnormal TSH ( less than 0.4 micro international units [uIU] per mL or greater than 4.0 uIU per mL), free thyroxine (T4) were evaluated for thyroid function. Rates of pulmonary function testing (PFT) were measured by the diffusion capacity of carbon monoxide tests (DLCO) and annual chest x-rays (CXR); electrocardiograms were not counted. Monitoring rates were compared using Pearson chi-square tests, and logistic regression was used to compare the odds of testing (ALT, TSH, T4, CXR, PFT) between the 2 groups at any time during the year after the index date. Concomitant uses of amiodarone with high-dose statins and of amiodarone with digoxin were compared using Pearson chi-square tests. Hospitalizations and emergency room (ER) visits during the 12-month follow-up period were counted for (a) interstitial lung disease; (b) rhabdomyolysis for patients who received amiodarone with high-dose statins (either lovastatin greater than 40 mg per day or greater than 20 mg per day of simvastatin or atorvastatin); and (c) for patients with abnormal digoxin, ALT, TSH, or T4 levels, if the hospitalization occurred within 2 days of the abnormal laboratory value. RESULTS There were 2,292 patients who received at least 100 days of amiodarone therapy and met the other inclusion criteria, of whom 181 patients (7.9%) were in the pharmacist-managed group and 2,111 received usual care. There were 90 (49.7%) new amiodarone users in the pharmacist-managed group and 990 (46.9%) in usual care. The 2 groups had similar demographic characteristics except race, with more whites and fewer African Americans, Asians, and Hispanics in usual care. Laboratory monitoring rates for ALT, TSH, and T4 were significantly higher in the pharmacist-managed group than usual care at the first and second 6 months and at baseline for ALT and TSH but not T4. Baseline CXR rates were significantly higher for the pharmacist-managed group than usual care (59.1% vs. 49.3%; P=0.011). Few patients in either group received PFT tests at baseline, 6.6% versus 3.6% (P=0.042). After controlling for covariates (age, gender, race, new vs. continuing use, and comorbidities), pharmacist-managed patients were significantly more likely to have at least 1 ALT test within the year after the index prescription (odds ratio [OR]=3.13, 95% CI=1.12-8.71), as well as a TSH test (OR=8.13, 95% CI=3.27-20.21) and T4 (OR=2.51, 95% CI=1.67-3.75). PFTs were also more likely to be given to these patients (OR=5.89, 95% CI=3.86-8.99). A higher percentage of patients in the pharmacist-managed group than in usual care were taking a high-dose statin during the 12-month follow-up period (47.5% vs. 36.2%, P=0.003), but of those patients, a greater proportion were switched to another statin (14.0% [n=12] vs. 7.5% [n=57], P=0.037) or a lower dose (9.3% [n=8] vs. 3.9% [n=30], P=0.022). Six patients in the usual care group (0.79% of patients on high-dose statins) developed rhabdomyolysis, and 5 (0.24% of all patients in usual care) had an admission for interstitial lung disease. The proportions of patients using amiodarone and digoxin concomitantly were similar in the 2 groups (35.9% vs. 31.3%, P=0.197). Among patients with abnormal laboratory results for ALT, TSH, and T4, or digoxin, there were 2 all-cause hospitalizations and 1 ER visit in the pharmacist-managed group and 34 all-cause hospitalizations and 18 ER visits in the usual care group during the follow-up year. Assuming that all hospitalizations and ER visits incurred in the usual care group were avoid- able, approximately $2.14 could be saved for every dollar spent on the pharmacist-managed amiodarone monitoring program. CONCLUSIONS Pharmacist management of patients treated with amiodarone was associated with improved monitoring of recommended laboratory tests and PFTs.
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Affiliation(s)
- Michele M. Spence
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
| | - Jennifer K. Polzin
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
| | - Calvin L. Weisberger
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
| | - John P. Martin
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
| | - Jay P. Rho
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
| | - Giselle H. Willick
- Kaiser Permanente, Pharmacy Outcomes Research Group, 12254 Bellflower Blvd., Downey, CA 90242, USA.
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Expanded coverage for warfarin patients in the USA monitoring clotting time at home. Cardiovasc J Afr 2011; 22:280. [PMID: 21983956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
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Setiabudy R. Therapeutic drug monitoring: focus on conditions in Indonesia. Acta Med Indones 2011; 43:208-211. [PMID: 21979288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
It has been long recognized that large inter-individual variability is commonly observed in response to drug administration. The large response variability of certain drugs with narrow margin of safety may induce toxicity. To avoid this and to optimize the result of drug treatment, therapeutic drug monitoring (TDM) service has been routinely applied in hospitals in well-developed countries. For certain drugs, the TDM service has been shown beneficial and cost-effective. In Indonesia, the TDM has not yet been implemented. There are three problems that hamper the implementation of TDM here, i.e. cost, the limited expertise to provide interpretation for result of drug assay, and the lack of communication with the clinicians. Today the patient safety issue is considered of paramount importance in the health care service in all hospitals. Therefore, it is now the time to commence the TDM service in Indonesia. This can be started with a pilot project in a large hospital, followed by the others. To avoid unnecesary wasting of funds, TDM should be limited for drugs which toxicity is not readily observed clinically.
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Affiliation(s)
- Rianto Setiabudy
- Department of Pharmacology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia.
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Argenta C, Ferreira MAP, Sander GB, Moreira LB. Short-term therapy with enoxaparin or unfractionated heparin for venous thromboembolism in hospitalized patients: utilization study and cost-minimization analysis. Value Health 2011; 14:S89-S92. [PMID: 21839908 DOI: 10.1016/j.jval.2011.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To evaluate the direct costs of venous thromboembolism (VTE) treatment with unfractionated heparin (UFH) and low-molecular weight heparin, from the institutional perspective. METHODS This is a real-world cohort study that included inpatients treated with UFH or enoxaparin for deep venous thromboembolism or pulmonary embolism in a tertiary public hospital. To estimate medical costs we computed the acquisition costs of drugs, supplies for administration, laboratory tests, and hospitalization cost according to the patient ward. RESULTS One hundred sixty-seven patients aged 18 to 92 years were studied (50 treated with UFH and 117 with enoxaparin). The median of days in use of heparin was the same in both groups. Activated partial thromboplastin time was monitored in 98% of patients using UFH and 56.4% using enoxaparin. Nonstatistically significant differences were observed between groups in the number of bleeding events (10.0% and 9.4%; P = 1.00); blood transfusion (2.0% and 2.6%; P = 1.00); death (8.0% and 3.4%; P = 0.24); and recurrent VTE, bleeding, or death (20.0% and 14.5%; P = 0.38). Daily mean cost per patient was US$12.63 ± $4.01 for UFH and US$9.87 ± $2.44 for enoxaparin (P < 0.001). The total costs considering the mean time of use were US$88.39 and US$69.11. CONCLUSION The treatment of VTE with enoxaparin provided cost savings in a large teaching hospital located in southern Brazil.
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Affiliation(s)
- Catia Argenta
- Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Fendrick AM. A pharmacoeconomic perspective on stroke prevention in atrial fibrillation. Am J Manag Care 2010; 16:S284-S290. [PMID: 21517643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Atrial fibrillation (AF) is predictive of higher costs for stroke care, in part due to the influence of AF on stroke severity. Costs associated with severe strokes, which are more likely in patients with AF, are about twice those of mild strokes. Thus, adequately weighing the costs associated with stroke care is important when making prevention and treatment recommendations for patients diagnosed with AF. Costs associated with AF are estimated at $6.65 billion annually, which breaks down to 44% for hospitalizations, 29% for the incremental inpatient costs of AF as a comorbid diagnosis, 23% for outpatient treatment of AF, and 4% for medications. A diagnosis of AF should be followed by careful consideration of the treatment plan. Clinicians who tend to underuse warfarin should consider whether the patient has valid contraindications to warfarin or if the risk of stroke would be unacceptably high using the alternative--low-dose aspirin. Optimal use of anticoagulation in patients with AF is projected to result in substantial savings in direct costs. Optimization of anticoagulation therapy in only half of the suboptimally anticoagulated patients with AF would save approximately $1.3 billion annually. New and emerging oral alternatives to warfarin promise to combine the advantages of oral dosing and effective anticoagulation with improvements in safety, leading to reduced monitoring and dose adjustment. As these agents become available, treatment decisions will likely incorporate economic considerations, such as the costs of medication, patient monitoring, and treatment of bleeding events.
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Walensky RP, Ciaranello AL, Park JE, Freedberg KA. Cost-effectiveness of laboratory monitoring in sub-Saharan Africa: a review of the current literature. Clin Infect Dis 2010; 51:85-92. [PMID: 20482371 PMCID: PMC2880656 DOI: 10.1086/653119] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
As the global community evaluates the unprecedented investment in the scale-up of human immunodeficiency virus (HIV) therapy and considers future investments in HIV care, it is crucial to identify those HIV interventions that maximize the benefit realized from each dollar spent. The use of laboratory monitoring assays--CD4 cell count and HIV RNA level--in decisions about when to initiate and switch antiretroviral therapy may offer substantial clinical benefit, but their economic value remains controversial. Cost-effectiveness analysis can be used to evaluate the value for money of strategies for HIV care, including alternative approaches to laboratory monitoring. Five published cost-effectiveness analyses address the question of CD4 cell count and HIV RNA level monitoring for HIV-infected patients in Africa, with differing conclusions. We describe the use of cost-effectiveness analysis in resource-limited settings and review the cost-effectiveness literature with regard to monitoring the CD4 cell count and HIV RNA level in Africa, highlighting some of the most critical issues in this debate.
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Affiliation(s)
- Rochelle P Walensky
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Nakatani SM, Santos CA, Riediger IN, Krieger MA, Duarte CAB, Lacerda MA, Biondo AW, Carilho FJ, Ono-Nita SK. Development of hepatitis C virus genotyping by real-time PCR based on the NS5B region. PLoS One 2010; 5:e10150. [PMID: 20405017 PMCID: PMC2854153 DOI: 10.1371/journal.pone.0010150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 02/23/2010] [Indexed: 01/31/2023] Open
Abstract
Background Hepatitis C virus (HCV) genotyping is the most significant predictor of the response to antiviral therapy. The aim of this study was to develop and evaluate a novel real-time PCR method for HCV genotyping based on the NS5B region. Methodology/Principal Findings Two triplex reaction sets were designed, one to detect genotypes 1a, 1b and 3a; and another to detect genotypes 2a, 2b, and 2c. This approach had an overall sensitivity of 97.0%, detecting 295 of the 304 tested samples. All samples genotyped by real-time PCR had the same type that was assigned using LiPA version 1 (Line in Probe Assay). Although LiPA v. 1 was not able to subtype 68 of the 295 samples (23.0%) and rendered different subtype results from those assigned by real-time PCR for 12/295 samples (4.0%), NS5B sequencing and real-time PCR results agreed in all 146 tested cases. Analytical sensitivity of the real-time PCR assay was determined by end-point dilution of the 5000 IU/ml member of the OptiQuant HCV RNA panel. The lower limit of detection was estimated to be 125 IU/ml for genotype 3a, 250 IU/ml for genotypes 1b and 2b, and 500 IU/ml for genotype 1a. Conclusions/Significance The total time required for performing this assay was two hours, compared to four hours required for LiPA v. 1 after PCR-amplification. Furthermore, the estimated reaction cost was nine times lower than that of available commercial methods in Brazil. Thus, we have developed an efficient, feasible, and affordable method for HCV genotype identification.
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Affiliation(s)
- Sueli M. Nakatani
- Laboratório Central do Estado (LACEN-PR), São José dos Pinhais, Paraná, Brazil
- Department of Gastroenterology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | | | - Irina N. Riediger
- Laboratório Central do Estado (LACEN-PR), São José dos Pinhais, Paraná, Brazil
- Departamento de Biologia Celular, Universidade Federal do Paraná, Curitiba, Brazil
| | - Marco A. Krieger
- Instituto Carlos Chagas – Fundação Oswaldo Cruz (ICC-FioCruz), Curitiba, Paraná, Brazil
| | - Cesar A. B. Duarte
- Instituto Carlos Chagas – Fundação Oswaldo Cruz (ICC-FioCruz), Curitiba, Paraná, Brazil
| | - Marco A. Lacerda
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, United States of America
| | - Alexander W. Biondo
- Department of Veterinary Medicine, Federal University of Paraná, Curitiba, Brazil
- Department of Pathobiology, University of Illinois, Urbana, Illinois, United States of America
| | - Flair J. Carilho
- Department of Gastroenterology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Suzane K. Ono-Nita
- Department of Gastroenterology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
- * E-mail:
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Breda M, Barattè S. A review of analytical methods for the determination of 5-fluorouracil in biological matrices. Anal Bioanal Chem 2010; 397:1191-201. [PMID: 20383700 DOI: 10.1007/s00216-010-3633-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Revised: 02/24/2010] [Accepted: 03/03/2010] [Indexed: 11/26/2022]
Abstract
5-Fluorouracil (5-FU) is a cytostatic agent that has been widely used in the treatment of various solid tumours for more than 20 years, and is still considered to be among the most active antineoplastic agents in advanced colorectal cancer and malignancies of the head and neck. A large number of non-chromatographic and chromatographic methods for the quantitation of 5-FU, related prodrugs and their metabolites in biological matrices have been developed in the last 30 years to support preclinical and clinical studies. However, 5-FU monitoring has not been widely used, at least not in the USA, and certainly not outside the clinical research setting, given the absence of simple, fast and inexpensive testing methods for 5-FU monitoring. Recent developments with testing based on liquid chromatography-tandem mass spectrometry and a nanoparticle antibody-based immunoassay may facilitate routine monitoring of 5-FU in daily clinical practice. In this review the advantages and disadvantages of the bioanalytical methods developed and used for 5-FU, its metabolites and related prodrugs are discussed.
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Affiliation(s)
- Massimo Breda
- Accelera S.r.l., Viale Pasteur 10, 20014 Nerviano, Italy.
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Garcia-Marcos L, Brand PL. The utility of sputum eosinophils and exhaled nitric oxide for monitoring asthma control with special attention to childhood asthma. Allergol Immunopathol (Madr) 2010; 38:41-6. [PMID: 20056307 DOI: 10.1016/j.aller.2009.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 10/30/2009] [Indexed: 11/18/2022]
Abstract
The monitoring of sputum eosinophils has received certain attention as a tool for improving asthma management both in children and in adults. The present paper reviews the technique and also the usefulness of induced sputum in the diagnosis and assessment of asthma, together with its ability to predict the response to treatment and to anticipate asthma exacerbations. Special attention is addressed to childhood asthma. The authors conclude that due to cost-effectiveness reasons derived from high labour costs, together with the unpleasantness of the technique and the failure to obtain adequate samples in a non-negligible percentage of children, this technique should be only used for research purposes.
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Affiliation(s)
- L Garcia-Marcos
- Paediatric Respiratory Unit, Virgen de la Arrixaca University Children's Hospital, University of Murcia, Murcia, Spain.
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Abstract
OBJECTIVE Rhythm- and rate-control therapies are an essential part of atrial fibrillation (AF) management; however, the use of existing agents is often limited by the occurrence of adverse events. The aim of this study was to evaluate suspected adverse events and adverse event monitoring, and associated medical costs, in patients receiving AF rhythm-control and/or rate-control therapy. RESEARCH DESIGN AND METHODS This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from 2002-2006. Patients hospitalized for AF (primary diagnosis), and who had at least 365 days' enrollment before and after the initial (index) AF hospitalization, were included in the analysis. Suspected AF therapy-related adverse events and function tests for adverse event monitoring were identified according to pre-specified diagnosis codes/procedures, and examined over the 12 months following discharge from the index hospitalization. Events/function tests had to have occurred within 90 days of a claim for AF therapy to be considered a suspected adverse event/adverse event monitoring. RESULTS Of 4174 AF patients meeting the study criteria, 3323 received AF drugs; 428 received rhythm-control only (12.9%), 2130 rate-control only (64.1%), and 765 combined rhythm/rate-control therapy (23.0%). Overall, 50.1% of treated patients had a suspected adverse event and/or function test for adverse event monitoring (45.5% with rate-control, 53.5% with rhythm-control, and 61.2% with combined rhythm/rate-control). Suspected cardiovascular adverse events were the most common events (occurring in 36.1% of patients), followed by pulmonary (6.1%), and endocrine events (5.9%). Overall, suspected adverse events/function tests were associated with mean annual per-patient costs of $3089 ($1750 with rhythm-control, $2041 with rate control, and $6755 with combined rhythm/rate-control). LIMITATIONS As a retrospective analysis, the study is subject to potential selection bias, while its reliance on diagnostic codes for identification of AF and suspected adverse events is a source of potential investigator error. A direct cause-effect relationship between suspected adverse events/function tests and AF therapy cannot be confirmed based on the claims data available. CONCLUSIONS The incidence of suspected adverse events and adverse event monitoring during AF rhythm-control and/or rate-control therapy is high. Costs associated with adverse events and adverse event monitoring are likely to add considerably to the overall burden of AF management.
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Affiliation(s)
- M H Kim
- Northwestern University, Chicago, IL 60611, USA.
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Smith DH, Feldstein AC, Perrin NA, Yang X, Rix MM, Raebel MA, Magid DJ, Simon SR, Soumerai SB. Improving laboratory monitoring of medications: an economic analysis alongside a clinical trial. Am J Manag Care 2009; 15:281-289. [PMID: 19435396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To test the efficiency and cost-effectiveness of interventions aimed at enhancing laboratory monitoring of medication. STUDY DESIGN Cost-effectiveness analysis. METHODS Patients of a not-for-profit, group-model HMO were randomized to 1 of 4 interventions: an electronic medical record reminder to the clinician, an automated voice message to patients, pharmacy-led outreach, or usual care. Patients were followed for 25 days to determine completion of all recommended baseline laboratory monitoring tests. We measured the rate of laboratory test completion and the cost-effectiveness of each intervention. Direct medical care costs to the HMO (repeated testing, extra visits, and intervention costs) were determined using trial data and a mix of other data sources. RESULTS The average cost of patient contact was $5.45 in the pharmacy-led intervention, $7.00 in the electronic reminder intervention, and $4.64 in the automated voice message reminder intervention. The electronic medical record intervention was more costly and less effective than other methods. The automated voice message intervention had an incremental cost-effectiveness ratio (ICER) of $47 per additional completed case, and the pharmacy intervention had an ICER of $64 per additional completed case. CONCLUSIONS Using the data available to compare strategies to enhance baseline monitoring, direct clinician messaging was not an efficient use of resources. Depending on a decision maker's willingness to pay, automated voice messaging and pharmacy-led efforts can be efficient choices to prompt therapeutic baseline monitoring, but direct clinician messaging is probably a less efficient use of resources.
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Affiliation(s)
- David H Smith
- Center for Health Research, Kaiser Permanente, 3800 N Interstate Ave, Portland, OR 97227, USA.
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