Antonio P. Legorreta

Costs and Clinical Outcomes after Coronary Multidetector CT Angiography in Patients without Known Coronary Artery Disease: Comparison to Myocardial Perfusion SPECT

PURPOSE To assess costs and clinical outcomes in individuals without known coronary artery disease (CAD) who underwent multidetector computed tomographic (CT) angiography compared with those in matched patients who underwent myocardial perfusion single photon emission computed tomography (SPECT). MATERIALS AND METHODS Data were captured from a deidentified, HIPAA-compliant data warehouse. We examined 1-year CAD costs (additional diagnostic coronary testing, CAD hospitalization, and coronary procedural and revascularization costs) and clinical outcomes in individuals without known CAD who underwent multidetector CT (n = 1647) compared with those in a matched cohort of patients who underwent myocardial perfusion SPECT (n = 6588). Cox proportional hazards models were employed for clinical outcome measures, including CAD hospitalization, myocardial infarction, and angina. RESULTS Adjusted CAD costs in the multidetector CT group were 25.9% lower than in the myocardial perfusion SPECT group, by an average of

Asthma-related exacerbations, therapy switching, and therapy discontinuation : a comparison of 3 commonly used controller regimens

1075 (95% confidence interval [CI]:

Adherence to combined Lamivudine+Zidovudine versus individual components: A community-based retrospective medicaid claims analysis

243,

Examining the Use of Breast-conserving Treatment for Women With Breast Cancer in a Managed Care Environment

2570) per patient. Those in the multidetector CT group were more likely to undergo downstream testing with myocardial perfusion SPECT (odds ratio, 6.65; 95% CI: 5.05, 8.75; P < .001), while those in the myocardial perfusion SPECT group were more likely to undergo downstream testing with invasive angiography (odds ratio, 6.25; 95% CI: 4.35, 9.09; P < .001). The multidetector CT group was less likely to undergo coronary revascularization (hazard ratio, 0.76; 95% CI: 0.75, 0.77; P < .001) than the myocardial perfusion SPECT group. There was no significant difference between multidetector CT and myocardial perfusion SPECT groups for rates of myocardial infarction (0.4% for both) or CAD hospitalization (0.7% vs 1.1%, respectively), while rates of angina were significantly lower in the multidetector CT group (4.3% vs 6.4%, P < .001). CONCLUSION Individuals without known CAD who underwent multidetector CT as an initial diagnostic test, compared with those who underwent myocardial perfusion SPECT, incurred lower health care costs with similar rates of myocardial infarction and CAD-related hospitalization.

A Quality‐Driven Physician Compensation Model: Four‐Year Follow‐up Study

BACKGROUND Asthma control is the goal of therapeutic interventions. In observational studies, the use of short-acting beta-agonists (SABAs) is a surrogate for symptoms and emergency department or hospital events for exacerbations. OBJECTIVE To compare asthma exacerbations, medication switch, and use of SABAs among 3 treatment cohorts: fluticasone propionate and salmeterol as a single inhaler (FSC), fluticasone and salmeterol as separate inhalers (FP + SAL), and fluticasone propionate alone (FP). METHODS Administrative claims data from approximately 10 million individuals from April 2000 to December 2002 were examined. Patients 15 years or older with claims for asthma, SABAs, and study medications were included in the study. Asthma-related medical and pharmacy claims were evaluated. Multivariate regression techniques were used to model the outcomes of interest, controlling for patient characteristics. RESULTS The odds of a hospitalization or emergency department event were significantly lower for the patients receiving FSC (n=1013) compared with those receiving FP (n=1130) (odds ratio, 0.75; 95% confidence interval, 0.61-0.93) and those receiving FP + SAL (n=271) (odds ratio, 0.69; 95% confidence interval, 0.51-0.95). Patients receiving FSC also had a significantly lower risk of switch or discontinuation of index medication and lower rates of postindex SABA use. CONCLUSION In this analysis, patients receiving FSC had lower rates of asthma-related symptoms and exacerbations as measured by SABA refills and hospitalization, respectively, when compared with patients receiving either FP or FP + SAL. This observational examination of medical and pharmacy claims data adds to the clinical reports that demonstrate the increased effectiveness of FSC when compared with FP or FP + SAL.

Linking the US transplant registry to administrative claims data: expanding the potential of transplant research.

Abstract Adherence to a fixed dose combination of dual nucleoside antiretroviral therapy was compared between human immunodeficiency virus (HIV)–infected patients newly started on a fixed dosed combination of lamivudine (3TC) 150 mg/zidovudine (ZDV) 300 mg versus its components taken as separate pills. Medicaid pharmacy claims data were used for analyses. To examine the association between treatment group and medication adherence, three types of multivariate regressions were employed. In addition, all regressions were conducted for the whole population using data from 1995 to 2001 as well as a subpopulation, which excluded data prior to September 1997. Model covariates included patient characteristics, healthcare utilization, and non-study antiretroviral therapy use. The likelihood of ≥95% adherence among patients on combination therapy was three times greater than patients taking 3TC and ZDV in separate pills. Also, combination therapy patients had on average 1.4 fewer adherence failures per year of follow-up and nearly double the time to adherence failure compared to the separate pills group. Consistency among study results suggests that fixed dose combination therapies such as lamivudine (3TC) 150 mg/ zidovudine (ZDV) 300 mg should be considered when prescribing HIV treatment that includes an appropriate dual nucleoside.

Comparing outcomes in patients with persistent asthma: a registry of two therapeutic alternatives*

At a National Institutes of Health Consensus Conference in 1991, conservation treatment was considered preferable for patients with early-stage breast cancer. In the early and mid-1990s, however, less than half of the eligible patients received this treatment and the rates varied with patient and provider characteristics. This study explores whether more eligible patients with breast cancer received conservation treatment in recent years in a managed care environment compared to reports in the literature, and if patient and hospital characteristics affected the rate of acceptance. The study population included 753 women with breast cancer in clinical stages 0, I, or II. Patients with Stage III or IV tumors or with tumors larger that 5.0 cm were excluded. A multiple logistic regression incorporated in a mixed-effect model was used to estimate the effect of patient and facility characteristics on the likelihood of using breast-conserving surgery controlling for clinical stages and demographics such as age, race, and marital status. Among the 753 eligible patients, 474 (62.9%) received conservation surgery. Only Hispanic ethnicity and clinical stage significantly affected the likelihood of receiving conservation treatment. Factors such as patient age, hospital size, and teaching status that had been found to be significant predictors in earlier studies were not statistically significant in this study, although conservation treatment was more frequent in younger women and in teaching hospitals. A larger proportion of eligible patients received conservative treatment in this study than in previous reports. This treatment became available in a broader range of institutions, moving from large, academic teaching centers to smaller community hospitals.

Axillary node dissection in Ductal carcinoma in situ

This case report describes a qualitative and preliminary quantitative assessment of a quality-based physician compensation program. The Hawaii Medical Service Associations Physician Quality and Service Recognition program offers an innovative and effective approach for improving delivery of high-quality and cost-effective care to patients enrolled in preferred provider organizations. Support for the program is demonstrated through increasing numbers of voluntarily participating physicians. Preliminary assessment of population outcomes reveals sustained improvements in many clinical areas and mixed findings in others. This study contributes to the body of knowledge available to payers and policy makers considering alternative payment methods to reward improved performance.

Aligning financial incentives with quality of care in the hospital setting.

Objective: In the United States, data on transplanted and waitlisted patients collected by the Organ Procurement and Transplantation Network (OPTN) have been widely used in transplantation research. Administrative claims data, collected by health plans for reimbursement purposes, are also commonly used in health-services research. This study linked OPTN and private payer claims data to assess the relationship between data elements common to both sources. Methods: All transplanted or waitlisted patients in the registry were considered for inclusion. A multistep match algorithm was employed to link OPTN and payer data from years 1995 to 2004. Variables common to both datasets that contained relevant information for similar time periods were compared. Results: A total of 21,419 solid organ transplant recipients and 8808 waitlist patients were included in the final linked database. Organ type and demographic variable distributions in the linked dataset were similar to the overall OPTN database. Using claims as the reference group, sensitivity and specificity values were on average 0.72 and 0.69, respectively, and were highest for the indicators of immunosuppression use at discharge and follow-up. Conclusion: This comparison of payer data with information reported by transplant centers to the OPTN provides important insight into the value of both data sources. Using administrative claims to augment the registry data with utilization and cost information will be useful for evaluation of both economic and clinical endpoints in solid organ transplantation.

Differences in episode-based care costs for multidetector computed tomographic coronary angiography versus myocardial perfusion imaging for the diagnosis of coronary artery disease

ABSTRACT Objective: Clinical trials have demonstrated improved efficacy of fluticasone propionate/ salmeterol (100/50 mcg) in a single device (FSC) compared with montelukast (10 mg) (MON). This study was designed to assess asthma control, asthma-related quality of life, asthma-related emergency department (ED) visit/hospitalization, treatment-related satisfaction, and productivity losses in patients newly started on FSC or MON. Research design and methods: Patients who were newly prescribed FSC or MON during a regularly scheduled office visit were enrolled in a prospective observational study by nearly 500 physicians from eight managed care plans. Patient survey data were collected at baseline and at months 1, 3, 6, and 12, to measure study outcomes. ED visits/inpatient stays were reported from commercial claims data. Multivariate analyses assessed 12‐month outcomes, controlling for several baseline patient characteristics. Results: A total of 1414 patients ≥ 15 years old were enrolled in the registry (FSC, n = 1061; MON, n = 353), 90% of which completed a 12‐month survey. FSC patients had significantly greater improvement in both asthma control and quality of life, and reported significantly higher satisfaction with their medication ( p = 0.003) and fewer days at work/school with asthma symptoms ( p = 0.04) than MON. Other parameters of productivity losses such as missed work/school days due to asthma were not significantly different between the two groups. FSC use was also significantly associated with a lower risk of an asthma-related ED visit/hospitalization compared with MON (odds ratio = 0.35, 95% confidence interval: 0.15–0.92). Conclusion: In a 12‐month office-based observational study, patients age 15 and older with persistent asthma, newly started on FSC, improved in symptom, quality of life, treatment, and utilization-related outcomes compared with patients newly started on MON. These results should be interpreted in light of the inherent limitations of non-randomized, uncontrolled studies.