Bernard S. Bloom

Over-the-counter nonsteroidal anti-inflammatory drugs and risk of gastrointestinal symptoms

OBJECTIVE:Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications. Although much is known about prescription NSAIDs and risk of GI side effects, little is known about over-the-counter (OTC) NSAIDs and their risk of GI side effects. The aim of this study was to estimate use of OTC NSAIDs, GI side effects, and professional and self-care for these side effects.METHODS:We conducted a telephone survey of an age-stratified U.S. random sample of 535 persons at least 40 yr old, who used an OTC NSAID for 4 of the previous 7 days, and a matched comparison population of 1068 persons who used no NSAID within the previous 30 days. We measured current use of OTC NSAIDs, GI symptoms, diagnoses and their treatment, and prescription and OTC GI medications.RESULTS:The most commonly used OTC NSAID was aspirin (alone or in combination compounds). Prevention of myocardial infarction or stroke was the most common reason for use (43.2%), followed by all forms of pain relief (44.2%) and relief of arthritis symptoms (24.5%). NSAID users were twice as likely as nonusers to report GI side effects (19.6% vs 9.5%, p = 0.0001), and more than twice as likely to use an OTC GI medication when they had GI symptoms (46.7% vs 20.8%, p = 0.001).CONCLUSIONS:OTC NSAIDs are not a benign medication even at low dosages. Physicians may be unaware that patients self-medicate with OTC NSAIDs and for GI side effects with additional OTC GI medications. Therefore, physicians should routinely ask patients about all forms of self-treatment.

Changing availability and cost of Internet physician consultations and prescription medications

Introduction. Internet use by the public to obtain medical information and services continues to grow. In 1999, we found cost of general physician visits was 15% higher, and cost of medications was 10% greater via the Internet than from community providers. The goal of this study was to re-examine changes in product availability and costs to consumers four years later. Design. We searched multiple websites 1 June 2003 – 31 August 2004, offering physician consultations and prescription medications. We compared mean cost of Internet physician visits and price per pill to costs of community-based general physicians and pharmacies in the Philadelphia region. Results. We found 144 sites worldwide providing physician services and prescription medications. Mean charge for an Internet physician consultation was

Prospective payment and the Medicare Hospice Benefit

55, 8.3% lower than for a comparable visit to a community practitioner. Mean cost per pill across 204 available medications was 36.7% higher at Internet sites than at local pharmacies. Shipping and handling (S&H) added a mean of

Abruptly Changing Patterns of Diffusion and Use of Extracorporeal Shock-wave Renal Lithotripsy

15.40. Total cost to Internet consumers was similar whether or not Internet sites charged for a physician consultation and/or S&H. Obtaining physician visits and medications over the Internet was about 40% more costly than in the local community. Conclusion. The Internet continues to hold great promise for provision of health and medical care services by expanding access. However, increased access to physician care and medications entails higher cost, and quality of physician services and pharmaceuticals provided remain controversial.

The US Viewpoint

The objective of this study was to determine the effects of very high cost patients on hospice financial status. Ten Pennsylvania hospices dually certified by Medicare were randomly selected and agreed to participate. Patient age, sex, diagnosis, length of stay and payer were fairly uniform across hospices. Payments varied by diagnosis and payer. High cost patients were irregularly found in hospices; low cost patients were commonly and regularly distributed. Every hospice had at least one high cost patient. In one, the uncompensated payment for the 6.6 percent of patients defined as high cost (

Continuation of Initial Antihypertensive Medication After 1 Year of Therapy

7,300 and above) would have been 14.7 percent of total annual revenues. In another, uncompensated payments for high cost patients (9.8 percent) would have accounted for 17.2 percent of revenue. In 96.3 percent of the instances patients utilized less than the Medicare Hospice Benefit maximum allowable cost (

Observations on Urolithiasis Among American Troops in a Desert Area

7,300); and, 98.8 percent of the time patients stayed less than the maximum allowable length of time of 210 days. A logistic regression model found long length of stay (p < 0.0001), Medicare hospice benefit as primary payer (p <0.0001), any hospitalization during hospice stay (p < 0.003) and cerebrovascular disease diagnosis (p < 0.02) to be significantly related to high cost. Between the time the study was planned and completed, Medicare instituted a reinsurance program allowing unused funds below the maximum allowable limit from one patient to be used for patients who exhausted their benefits. Thus, no study hospice was adversely affected by high cost patients. However, it should serve as an object lesson to Medicare in using prospective payment. A normal or near-normal distribution of patients by cost cannot be assumed for small institutions.

Health related quality of life and direct medical care cost in newly diagnosed younger men with prostate cancer.

Early diffusion and use of extracorporeal shock-wave lithotripsy (ESWL) was found by a 1986 survey of the first 84 operational renal lithotripters in the United States to be similar to that of other equipment-embodied technologies. Resurvey in 1988 of this cohort of units found that clinical indications for ESWL treatment--stone size and location--expanded greatly. Professional fees for ESWL services remained essentially constant, while technical component charges increased 21.0%. Volume of procedures declined by 19.8% among the most productive units, and by 34.4% among the least productive study units; the previously noted approximate fourfold difference remained unchanged between most and least productive units. ESWL patterns of diffusion were comparable to other equipment-embodied diagnostic technology (magnetic resonance imaging [MRI] and computed tomography [CT]) during the first few years of clinical availability. ESWL growth slowed sooner than that of CT and MRI following their introduction into clinical practice, declining in the fourth to fifth year of use following rapid expansion in the first 2 years of availability. While clinical indications for both ESWL and imaging technologies expanded over time, CT and MRI experienced continued growth beyond that of ESWL at the same points of their respective life cycles. In the market areas of the 84 study units, the use of ESWL declined even with expanded indications for treatment, perhaps due to faster expansion of number of units than growth of clinical indications for treatment.

Issues in Mandatory Economic Assessment of Pharmaceuticals

Health and medical care services are not yet subject to the laws of supply and demand or the impersonal effects of the economic market. However, finite resources mean that governments and other payers are forced to make trade-offs. The United States, which has relied most heavily on market forces for its medical system, is now moving towards greater government responsibility for organization and financing, if not delivery, of services. President Clinton has proposed a national program of unified organization, service delivery, and financing so as to improve access to the US health care system and control cost. The proposed plan will enfranchise upwards of 50 million people who currently have no, or limited, access to medical care. Therefore, the initial effects will be more care of all kinds being provided by physicians. Such increases of services will increase expenditure, at least over the short-term.