Kit N. Simpson

Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals

Therapeutic inertia (TI), defined as the providers’ failure to increase therapy when treatment goals are unmet, contributes to the high prevalence of uncontrolled hypertension (≥140/90 mm Hg), but the quantitative impact is unknown. To address this gap, a retrospective cohort study was conducted on 7253 hypertensives that had ≥4 visits and ≥1 elevated blood pressure (BP) in 2003. A 1-year TI score was calculated for each patient as the difference between expected and observed medication change rates with higher scores reflecting greater TI. Antihypertensive therapy was increased on 13.1% of visits with uncontrolled BP. Systolic BP decreased in patients in the lowest quintile of the TI score but increased in those in the highest quintile (−6.8±0.5 versus +1.8±0.6 mm Hg; P<0.001). Individuals in the lowest TI quintile were ≈33 times more likely to have their BP controlled at the last visit than those in highest quintile (odds ratio, 32.7; 95% CI, 25.1 to 42.6; P<0.0001). By multivariable analysis, TI accounted for ≈19% of the variance in BP control. If TI scores were decreased ≈50%, that is, increasing medication dosages on ≈30% of visits, BP control would increase from the observed 45.1% to a projected 65.9% in 1 year. This study confirms the high rate of TI in uncontrolled hypertensive subjects. TI has a major impact on BP control in hypertensive subjects receiving regular care. Reducing TI is critical in attaining the Healthy People 2010 goal of controlling hypertension in 50% of all patients.

Polypharmacy: Misleading, but manageable

The percentage of the population described as elderly is growing, and a higher prevalence of multiple, chronic disease states must be managed concurrently. Healthcare practitioners must appropriately use medication for multiple diseases and avoid risks often associated with multiple medication use such as adverse effects, drug/drug interactions, drug/disease interactions, and inappropriate dosing. The purpose of this study is to identify a consensus definition for polypharmacy and evaluate its prevalence among elderly outpatients. The authors also sought to identify or develop a clinical tool which would assist healthcare practitioners guard against inappropriate drug therapy in elderly patients. The most commonly cited definition was a medication not matching a diagnosis. Inappropriate was part of definitions used frequently. Some definitions placed a numeric value on concurrent medications. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication. The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use. A structured approach to identify and manage inappropriate polypharmacy is suggested and a clinical tool is provided.

Sertraline in the treatment of co-occurring alcohol dependence and posttraumatic stress disorder

BACKGROUND Posttraumatic stress disorder (PTSD) frequently co-occurs with alcohol use disorders. This study investigated the use of sertraline, a serotonin reuptake inhibitor, in treating co-occurring symptoms of alcohol dependence and PTSD. METHODS A total of 94 individuals with current alcohol dependence and PTSD were randomly assigned to receive sertraline (150 mg/day) or placebo for 12 weeks. Post hoc cluster analysis of baseline characteristics was used to define subgroups of participants. RESULTS There was a significant decrease in alcohol use during the trial in both the sertraline and the placebo groups. Cluster analysis revealed significant medication group by cluster interactions for alcohol-related outcomes. Sertraline-treated participants with less severe alcohol dependence and early-onset PTSD had significantly fewer drinks per drinking day (p < 0.001). For participants with more severe alcohol dependence and later onset PTSD, the placebo group had significantly greater decreases in drinks per drinking day (p < 0.01) and average number of drinks consumed per day (p < 0.05). CONCLUSIONS There may be subtypes of alcohol-dependent individuals who respond differently to serotonin reuptake inhibitor treatment. Further investigation of differential responders may lead to improvements in the pharmacological treatment of co-occurring alcohol dependence and PTSD.

Economic decision analysis model of screening for lung cancer

The objective of this study was to evaluate the potential clinical and economic implications of an annual lung cancer screening programme based on helical computed tomography (CT). A decision analysis model was created using combined data from the Surveillance, Epidemiology and End Results (SEER) registry public-use database and published results from the Early Lung Cancer Action Project (ELCAP). We found that under optimal conditions in a high risk cohort of patients between 60 and 74 years of age, annual lung cancer screening over a period of 5 years appears to be cost effective at approximately

Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort.

19000 per life year saved. A sensitivity analysis of the model to account for a 1-year decrease in survival benefit and changes in assumptions for incidence rate and costs generated cost effectiveness estimates ranging from approximately

Modelling the Cost Effectiveness of Lamivudine/Zidovudine Combination Therapy in HIV Infection

10800 to

The One-Year Attributable Cost of Poststroke Aphasia

62000 per life year saved. Based on the assumptions embedded in this model, annual screening of high risk elderly patients for lung cancer may be cost effective under optimal conditions, but longer term data are needed to confirm if this will be borne out in practice.

Frequency, cost, and risk factors of readmissions among severe sepsis survivors.

The development of low-dose helical computed-tomography (CT) scanning to detect nodules as small as a few mm has sparked renewed interest in lung cancer (LC) screening. The objective of this study was to assess the potential health effects and cost-effectiveness of a one-time low-dose helical CT scan to screen for LC. We created a decision analysis model using baseline results from the Early Lung Cancer Action Project (ELCAP); Surveillance, Epidemiology and End Results (SEER) registry public-use database; screening program costs estimated from 1999 Medicare reimbursement rates; and annual costs of managing cancer and non-cancer patients from Riley et al. (1995) [Med Care 1995;33(8):828-841] and Taplin et al. (1995) [J Natl Cancer Inst 1995;87(6):417-26]. The main outcome measures included years of life, cost estimates of baseline diagnostic screening and follow up, and cost-effectiveness of screening. We found that in a very high-risk cohort (LC prevalence of 2.7%) of patients between 60 and 74 years of age, a one-time screen appears to be cost-effective at

Comparison of resting energy expenditure prediction methods with measured resting energy expenditure in obese, hospitalized adults.

5940 per life year saved. In a lower risk general population of smokers (LC prevalence of 0.7%), a one-time screen appears to be cost-effective at

Hospital Care for Patients Experiencing Weekend vs Weekday Stroke: A Comparison of Quality and Aggressiveness of Care

23100 per life year. Even when a lead-time bias of 1 year is incorporated into the model for a low risk population, the cost-effectiveness is estimated at