Anke Richter

The impact of reducing dose frequency on health outcomes

BACKGROUND Dosing schedules may be one important factor determining whether patients take their prescribed medication. Schedules may influence whether a patient stays on the prescribed therapy and, if so, the degree to which the regimen is followed. Both factors are important determinants of health outcomes and health care costs. OBJECTIVE The goal of this study was to investigate the impact of reducing dose frequency on health outcomes and health care costs. METHODS Articles from peer-reviewed journals were identified from the medical literature databases MEDLINE, International Pharmaceutical Abstracts, and HealthSTAR for the years 1985 through 2002. The search included all references that reported on the impact of a change of dose frequency on chronic disease. Search terms used were combinations of dose frequency, dose schedule, and dosing and efficacy, safety, clinical effectiveness, preferences, adherence, compliance, persistence, health-related quality of life, patient satisfaction, resource use, and costs. RESULTS Reducing the number of daily doses through extended-release formulations or newer drugs has frequently been shown to provide the patient with better symptom control in a number of disease states. Overall improvements were seen in adherence, patient quality of life, patient satisfaction, and costs. However, results of some studies indicate that not all patients, medications, or diseases may be candidates for reduced dosing due to the potential effects on symptom control, incidence of adverse events, and overcompensation for missed doses. CONCLUSION Where feasible, reducing dose frequency may offer benefits for the patient in terms of health outcomes and for the health care budget holder in terms of costs.

Resource allocation for control of infectious diseases in multiple independent populations: beyond cost-effectiveness analysis.

Traditional cost-effectiveness analysis (CEA) assumes that program costs and benefits scale linearly with investment-an unrealistic assumption for epidemic control programs. This paper combines epidemic modeling with optimization techniques to determine the optimal allocation of a limited resource for epidemic control among multiple noninteracting populations. We show that the optimal resource allocation depends on many factors including the size of each population, the state of the epidemic in each population before resources are allocated (e.g. infection prevalence and incidence), the length of the time horizon, and prevention program characteristics. We establish conditions that characterize the optimal solution in certain cases.

Potential Savings in the Cost of Caring for Alzheimer’s Disease

AbstractObjective: To estimate savings in the cost of caring for patientswith Alzheimer’s disease (AD) during 6 months, 1 year and 2 years of treatment with rivastigmine. An intermediate objective was to estimate the relationship between disease progression and institutionalisation.Design and setting: We assessed the relationship between Mini-Mental State Examination (MMSE) score and institutionalisation using a piecewise Cox proportional hazard model. To estimate cost savings from treatments lasting 6 months, 1 year and 2 years, estimates of the probability of institutionalisation were integrated with data from two 6-month phase III clinical trials of rivastigmine and a hazard model of disease progression.Main outcome measures and results: Our data suggest that savings in the overall cost of caring for patients with mild and moderate AD can be as high as

Optimal Allocation of Resources across Four Interventions for Type 2 Diabetes

US4839 per patient after 2 years of treatment. Furthermore, the probability of institutionalisation increases steadily as MMSE score falls. Among our study individuals, age, race, level of education and marital status were significant predictors of institutionalisation, whereas gender had little effect.Conclusions: Using rivastigmine to treat AD results in a delay in disease progression for patients who begin treatment during the mild or moderate stages of the disease. By delaying the probability that a patient will be institutionalised, the cost of caring for AD patients can be significantly reduced.

Patient characteristics and costs associated with dyslipidaemia and related conditions in HIV-infected patients: a retrospective cohort study

Background Several interventions can be applied to prevent complications of type 2 diabetes. This article examines the optimal allocation of resources across 4 interventions to treat patients newly diagnosed with type 2 diabetes. The interventions are intensive glycemic control, intensified hypertension control, cholesterol reduction, and smoking cessation. Methods A linear programming model was designed to select sets of interventions to maximize quality-adjusted life years (QALYs), subject to varied budget and equity constraints. Results For no additional cost, approximately 211,000 QALYs can be gained over the lifetimes of all persons newly diagnosed with diabetes by implementing interventions rather than standard care. With increased availability of funds, additional health benefits can be gained but with diminishing marginal returns. The impact of equity constraints is extensive compared to the solution with the same intervention costs and no equity constraint. Under the conditions modeled, intensified hypertension control and smoking cessation interventions were provided most often, and intensive glycemic control and cholesterol reduction interventions were provided less often. Conclusions A resource allocation model identifies trade-offs involved when imposing budget and equity constraints on care for individuals with newly diagnosed diabetes.

Characterizing and Diminishing Autofluorescence in Formalin-fixed Paraffin-embedded Human Respiratory Tissue.

Metabolic abnormalities are common in HIV‐infected individuals and, although multifactorial in origin, have been strongly associated with antiretroviral therapy.

Cost-Effectiveness Model of Cytomegalovirus Management Strategies in Renal Transplantation Comparing Valaciclovir Prophylaxis with Current Practice

Tissue autofluorescence frequently hampers visualization of immunofluorescent markers in formalin-fixed paraffin-embedded respiratory tissues. We assessed nine treatments reported to have efficacy in reducing autofluorescence in other tissue types. The three most efficacious were Eriochrome black T, Sudan black B and sodium borohydride, as measured using white light laser confocal Λ2 (multi-lambda) analysis. We also assessed the impact of steam antigen retrieval and serum application on human tracheal tissue autofluorescence. Functionally fitting this Λ2 data to 2-dimensional Gaussian surfaces revealed that steam antigen retrieval and serum application contribute minimally to autofluorescence and that the three treatments are disparately efficacious. Together, these studies provide a set of guidelines for diminishing autofluorescence in formalin-fixed paraffin-embedded human respiratory tissue. Additionally, these characterization techniques are transferable to similar questions in other tissue types, as demonstrated on frozen human liver tissue and paraffin-embedded mouse lung tissue fixed in different fixatives.

Assessing the Impact of Global Price Interdependencies

AbstractBackground: Cytomegalovirus (CMV) disease may occur following renal transplantation and has been shown to have health and cost consequences in this setting. Objective: To compare the cost effectiveness of different CMV management strategies for renal transplant patients: prophylaxis with (i) oral valaciclovir or (ii) intravenous ganciclovir; viral testing for CMV followed by (iii) pre-emptive therapy with intravenous ganciclovir or (iv) adjustment of immunosuppression and intensive monitoring; or (v) waiting to treat when CMV disease develops. Methods: A decision-tree model was constructed that included the different management strategies for the donor seropositive/recipient seronegative (D+R−) population. Clinical outcomes for the D+R− population came from clinical trials. Treatment algorithms and costs for CMV syndrome and tissue invasive disease were developed from published literature and UK physician interviews. One- and 2-way sensitivity analyses were performed. Study Perspective: UK National Health Service. Results: Prophylaxis with either oral valaciclovir or intravenous ganciclovir dominated (lower costs and fewer cases of CMV disease) the pre-emptive treatment and wait-and-treat strategies. The cost per patient was from £157 to £438 higher with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis and the incremental cost per case of CMV disease avoided with valaciclovir prophylaxis ranged from £2243 to £8111 (1996 values). These results are sensitive to the efficacy of intravenous ganciclovir prophylaxis and CMV management costs. Conclusions: For D+R− renal transplant patients, prophylaxis is the dominant (more effective and less costly) management strategy compared with pre-emptive and wait-and-treat strategies. The cost per patient with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis is slightly higher in our base case scenario, but may be lower under reasonable alternative assumptions.

Allocating HIV prevention resources: A tool for state and local decision making

Documented launch delays and the ensuing debate over their underlying causes have focused on assessment from the individual country’s perspective. Seen in a larger game theoretical framework this may cause problems, because although the countries see an individual game, the pharmaceutical firm sees a repeated linked game. The links are due to external reference pricing and parallel trade. Behaviours that are optimal in the single, individual game (for either the country or the pharmaceutical firm) may no longer be optimal when considering the global repeated game.A theoretical mixed integer linear model of the firm’s launch and pricing decisions is presented along with examples wherein international price dependencies most likely played a role. This model can help countries understand the implication of their external reference pricing policies on the global repeated pricing game. Understanding the behaviour of the pharmaceutical firm in this global context aids countries in designing policies to maximize the welfare of their citizens.

Pilot Model: Judging Alternate Modes of Dispensing Prophylaxis in Los Angeles County

The CDC provides funding for HIV prevention activities and state and local decision-makers must allocate these funds. The implementation of a resource allocation tool designed to facilitate this process that incorporates concepts of efficiency and equity as well as CDC mandates on the use of community planning groups is demonstrated, showing how information obtained from the resource allocation tool can be used to guide the policy analysis. The demonstration uses a simplified example based on data from Florida. The tool quantifies the inherent trade-offs associated with efficiency and equity and allows decision-makers to explore different ways of achieving equity. Given the underlying epidemiological model, results are not necessarily linear so common proportionality assumptions do not hold. However, a sense of equity can be provided by implementing various metrics allowing the policy maker flexibility in their decision process. By quantifying the impact of policy choices in terms of efficiency, cost, and distribution, the resource allocation tool makes the decision process more transparent and permits more informed choices.