Andreas Kuznik

Clinical and economic consequences of failure of initial antibiotic therapy for hospitalized patients with complicated skin and skin-structure infections.

OBJECTIVE To estimate the consequences of failure of initial antibiotic therapy for patients with complicated skin and skin-structure infections. DESIGN Retrospective cohort study. SETTING Large US multihospital database. PATIENTS We identified a total of 47,219 patients (age 18 years or older) who were admitted to the hospital for complicated skin and skin-structure infections from April 1, 2003, through March 31, 2004, and who received intravenous antibiotics during the first 2 hospital-days (ie, initial antibiotic therapy). Failure of therapy was defined as drainage, debridement, or receipt of other intravenous antibiotics at any subsequent time (except for changes to narrower-spectrum agents or any therapy change immediately before discharge). Predictors of failure of antibiotic therapy and mortality were examined using multivariate logistic regression. Analysis of covariance was used to estimate the impact of treatment failure on duration of intravenous antibiotic therapy, length of stay, and total inpatient charges. RESULTS For 10,782 admitted patients (22.8%), there was evidence of failure of initial antibiotic therapy. In multivariate analyses, treatment failure was associated with receipt of vasoactive medications during the first 2 hospital-days (odds ratio [OR], 1.66 [95% confidence interval {CI}, 1.19-2.31]), initiation of antibiotic therapy in the intensive care unit (OR, 1.53 [95% CI, 1.28-1.84]), and the patients Charlson comorbidity index (OR per 1-point increase, 1.06 [95% CI, 1.04-1.08]); treatment failure was also was associated with a 3-fold increase in mortality (OR, 2.91 [95% CI, 2.34-3.62]). Compared with patients for whom initial treatment was successful, patients who experienced treatment failure received intravenous antibiotic therapy for a mean of 5.7 additional days, were hospitalized for a mean of 5.4 additional days, and incurred a mean of

Cost-effectiveness of apixaban vs. current standard of care for stroke prevention in patients with atrial fibrillation.

5,285 (in 2003 dollars) in additional inpatient charges (all P<.01). CONCLUSION Failure of initial antibiotic therapy in the treatment of complicated skin and skin-structure infections is associated with significantly worse clinical and economic outcomes.

Trends in utilization of lipid- and blood pressure-lowering agents and goal attainment among the U.S. diabetic population, 1999-2008.

Aims Warfarin, a vitamin K antagonist (VKA), has been the standard of care for stroke prevention in patients with atrial fibrillation (AF). Aspirin is recommended for low-risk patients and those unsuitable for warfarin. Apixaban is an oral anticoagulant that has demonstrated better efficacy than warfarin and aspirin in the ARISTOTLE and AVERROES studies, respectively, and causes less bleeding than warfarin. We evaluated the potential cost-effectiveness of apixaban against warfarin and aspirin from the perspective of the UK payer perspective. Results and methods A lifetime Markov model was developed to evaluate the pharmacoeconomic impact of apixaban compared with warfarin and aspirin in VKA suitable and VKA unsuitable patients, respectively. Clinical events considered in the model include ischaemic stroke, haemorrhagic stroke, intracranial haemorrhage, other major bleed, clinically relevant non-major bleed, myocardial infarction, cardiovascular hospitalization and treatment discontinuations; data from the ARISTOTLE and AVERROES trials and published mortality rates and event-related utility rates were used in the model. Apixaban was projected to increase life expectancy and quality-adjusted life years (QALYs) compared with warfarin and aspirin. These gains were expected to be achieved at a drug acquisition-related cost increase over lifetime. The estimated incremental cost-effectiveness ratio was £11 909 and £7196 per QALY gained with apixaban compared with warfarin and aspirin, respectively. Sensitivity analyses indicated that results were robust to a wide range of inputs. Conclusions Based on randomized trial data, apixaban is a cost-effective alternative to warfarin and aspirin, in VKA suitable and VKA unsuitable patients with AF, respectively.

Cost-Effectiveness of Apixaban Versus Other New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation

BackgroundFor patients with diabetes, clinical practice guidelines recommend treating to a low-density lipoprotein cholesterol (LDL-C) goal of <2.59 mmol/L (100 mg/dL) and a blood pressure (BP) target of <130/80 mmHg. This analysis assessed recent trends in the utilization of lipid-lowering and BP-lowering agents, as well as LDL-C and BP goal attainment, in the U.S. adult diabetic population.Methods9,167 men and nonpregnant women aged ≥20 years were identified from the fasting subsample of the 1999-2008 National Health and Nutritional Examination Survey. Diabetes was identified in 1,214 participants by self report, self-reported use of insulin or oral medications for diabetes, or fasting glucose ≥6.99 mmol/L (126 mg/dL).ResultsThe prevalence of diagnosed or undiagnosed diabetes increased significantly over the past decade, from 7.4% in 1999-2000 to 11.9% in 2007-2008 (P = 0.0007). During this period, the use of lipid-lowering agents by participants with diabetes increased from 19.5% to 42.2% (P < 0.0001), and the proportion at LDL-C goal increased from 29.7% to 54.4% (P < 0.0001). Although there was a significant increase in antihypertensive medication use (from 35.4% to 58.9%; P < 0.0001), there was no significant change in the proportion of participants at BP goal (from 47.6% to 55.1%; P = 0.1333) or prevalence of hypertension (from 66.6% to 74.2%; P = 0.3724).ConclusionsThe proportion of diabetic individuals taking lipid- and BP-lowering agents has increased significantly in recent years. However, while there has been a significant improvement in LDL-C goal attainment, nearly one-half of all U.S. adults with diabetes are not at recommended LDL-C or BP treatment goals.

Cost Estimation of Cardiovascular Disease Events in the US

BACKGROUND Apixaban (5 mg BID), dabigatran (available as 150 mg and 110 mg BID in Europe), and rivaroxaban (20 mg once daily) are 3 novel oral anticoagulants (NOACs) currently approved for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE The objective of this study was to evaluate the cost-effectiveness of apixaban against other NOACs from the perspective of the United Kingdom National Health Services. METHODS A Markov model was developed to evaluate the pharmacoeconomic impact of apixaban versus other NOACs over a lifetime. Pair-wise indirect treatment comparisons were conducted against other NOACs by using ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy), and ROCKET-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial results for the following end points: ischemic stroke, hemorrhagic stroke, intracranial hemorrhage, other major bleeds, clinically relevant nonmajor bleeds, myocardial infarction, and treatment discontinuations. Outcomes were life-years, quality-adjusted life years gained, direct health care costs, and incremental cost-effectiveness ratios. RESULTS Apixaban was projected to increase life expectancy versus other NOACs, including dabigatran (both doses) and rivaroxaban. A small increase in therapeutic management costs was observed with apixaban due to projected gains in life expectancy and lower discontinuation rates anticipated on apixaban versus other NOACs through lifetime. The estimated incremental cost-effectiveness ratio was £9611, £4497, and £5305 per quality-adjusted life-year gained with apixaban compared with dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily, respectively. Sensitivity analyses indicated that results were robust over a wide range of inputs. CONCLUSIONS Although our analysis was limited by the absence of head-to-head trials, based on the indirect comparison data available, our model projects that apixaban may be a cost-effective alternative to dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily for stroke prevention in AF patients from the perspective of the United Kingdom National Health Services.

Evaluation of cardiovascular disease burden and therapeutic goal attainment in US adults with chronic kidney disease: an analysis of national health and nutritional examination survey data, 2001–2010

Background: In this study, we developed cost prediction equations that facilitate estimation of the costs of various cardiovascular events for patients of specific demographic and clinical characteristics over varying time horizons.Methods: We used administrative claims data and generalized linear models to develop cost prediction equations for selected cardiovascular events, including myocardial infarction (MI), angina, strokes and revascularization procedures. Separate equations were estimated for patients with events and for their propensity score-matched controls. Attributable costs were estimated on a monthly basis for the first 36 months after each event and annually thereafter, with differences in survival between cases and controls factored into the longitudinal cost calculations. The regression models were used to estimate event costs (

Switching from atorvastatin to simvastatin in patients at high cardiovascular risk: effects on low-density lipoprotein cholesterol.

US, year 2007 values) for the average patient in each event group, over various time periods ranging from 1 month to lifetime.Results: When the equations are run for the average patient in each event group, attributable costs of each event in the acute phase (i.e. first 3 years) are substantial (e.g. MI

Evaluating the cost-effectiveness of combination antiretroviral therapy for the prevention of mother-to-child transmission of HIV in Uganda

US73 300; hospitalization for angina

Comparison of Cardiovascular Event Rates in Patients Without Cardiovascular Disease in Whom Atorvastatin or Simvastatin Was Newly Initiated

US36 000; nonfatal haemorrhagic stroke

Cardiovascular and economic outcomes after initiation of lipid-lowering therapy with atorvastatin vs simvastatin in an employed population.

US71 600). Furthermore, for most events, cumulative costs remain substantially higher among cases than among controls over the remaining lifetime of the patients.Conclusions: This study provides updated estimates of medical care costs of cardiovascular events among a managed care population over various time horizons. Results suggest that the economic burden of cardiovascular disease is substantial, both in the acute phase as well as over the longer term.