Judith S. Hurley

Quality of Anticoagulation Control and Costs of Monitoring Warfarin Therapy among Patients with Atrial Fibrillation in Clinic Settings: A Multi-Site Managed-Care Study

BACKGROUND: Warfarin is recommended for prevention of stroke in patients with atrial fibrillation who are at moderate or high risk, but requires intensive management to achieve safe and optimal anticoagulation control. Anticoagulation clinics are often used to administer warfarin therapy more effectively. OBJECTIVE: To collect data from multiple sites and assess the quality and costs associated with anticoagulation clinic services. METHODS: A random sample of 600 adults with chronic nonvalvular atrial fibrillation (CNVAF) receiving warfarin was selected from anticoagulation clinics affiliated with 3 health plans. Patients were identified between 1996 and 1998 and followed for up to one year. We assessed the proportion of time that international normalized ratio (INR) values were within the recommended range (2.0–3.0) and the costs of anticoagulation clinic care. RESULTS: Patients had an average of 18 clinic contacts over a mean duration of follow-up of 10.5 months. On average, patients were within the recommended INR range 62% of this time, with 25% of days below range and 13% above range. The mean per-patient cost of warfarin monitoring over the follow-up period averaged

Use of Services by Diabetes Patients in Managed Care Organizations: Development of a diabetes surveillance system

261 at site A,

Laboratory safety monitoring of chronic medications in ambulatory care settings.

305 at site B, and

A comparison of two methods for estimating the health care costs of epilepsy.

205 at site C (in 2003 US

The role of combination inhaled corticosteroid/long-acting β-agonist therapy in COPD management

). Mean costs for patients treated for one full year were

Serological evaluation of Cryptosporidium oocyst findings in the water supply for Sydney, Australia.

288,

The role of fluticasone propionate/salmeterol combination therapy in preventing exacerbations of COPD

339, and

Health Care Utilization in Chronic Obstructive Pulmonary Disease A Case-Control Study in a Health Maintenance Organization

216, respectively. CONCLUSIONS: In 3 geographically diverse health plans, anticoagulation clinics provided a generally higher quality of control than previously reported in other observational studies. This study highlights the costs of obtaining this level of control.

Costs and Clinical Outcomes Associated With Low-Molecular-Weight Heparin vs Unfractionated Heparin for Perioperative Bridging in Patients Receiving Long-term Oral Anticoagulant Therapy*

OBJECTIVE Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identifydiabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators weredetermined. RESEARCH DESIGN AND METHODS Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined RESULTS An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in codingdata, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32–34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72–;94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29–;60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

Management of Acute Proximal Deep Vein Thrombosis: Pharmacoeconomic Evaluation of Outpatient Treatment With Enoxaparin vs Inpatient Treatment With Unfractionated Heparin

AbstractOBJECTIVE: To evaluate laboratory safety monitoring in patients taking selected chronic prescription drugs. DESIGN: Retrospective study using 1999–2001 claims data to calculate rates of missed laboratory tests (potential laboratory monitoring errors). Eleven drugs/drug groups and 64 laboratory tests were evaluated. SETTING: Two staff/network model health maintenance organizations. PATIENTS: Continuously enrolled health plan members age≥19 years taking ≥1 chronic medications. MEASUREMENTS AND MAIN RESULTS: Among patients taking chronic medications (N=29,823 in 1999, N=32,423 in 2000, and N=36,811 in 2001), 47.1% in 1999, 45.0% in 2000, and 44.0% in 2001 did not receive ≥1 test recommended for safety monitoring. Taking into account that patients were sometimes missing more than 1 test for a given drug and that patients were frequently taking multiple drugs, the rate of all potential laboratory monitoring errors was 849/1,000 patients/year in 1999, 810/1,000 patients/year in 2000, and 797/1,000 patients/year in 2001. Rates of potential laboratory monitoring errors varied considerably across individual drugs and laboratory tests. CONCLUSIONS: Lapses in laboratory monitoring of patients taking selected chronic medications were common. Further research is needed to determine whether, and to what extent, this failure to monitor patients is associated with adverse clinical outcomes.