Patrick W. Sullivan

The Cost Effectiveness of Anticoagulation Management Services for Patients with Atrial Fibrillation and at High Risk of Stroke in the US

BackgroundAnticoagulation therapy with warfarin is widely considered the standard of care for stoke prophylaxis in patients with atrial fibrillation who are at high risk of stroke. Community-based studies in the US have reported that the effectiveness of anticoagulation varies by management approach and that patients receiving warfarin have international normalised ratio (INR) values within the target therapeutic range less than half the time.ObjectiveTo estimate the lifetime societal costs and health benefits of warfarin therapy to prevent strokes, specifically in elderly patients (mean age 70 years) with atrial fibrillation who are at high risk of stroke, when anticoagulation is managed through usual care versus anticoagulation management services, where dedicated anticoagulation professionals (e.g. physician or pharmacist) monitor and oversee patients.MethodsSemi-Markov decision model with a 30-day cycle length and 10-year time horizon (to reflect the mean life expectancy of the study population). Univariate sensitivity analyses and Bayesian second-order multivariate probabilistic sensitivity analysis using Monte Carlo simulation were performed.Outcomes measures were costs and QALYs. Most of the probability and outcome estimates included were derived from the recent SPORTIF (Stroke Prevention using ORal Thrombin Inhibitor in atrial Fibrillation) V trial. Utility values were derived from a large, nationally representative sample of individuals in the Medical Expenditure Panel Survey and were adjusted for age, sex, race, ethnicity, income, education and co-morbidity. Resource utilisation was based on experience at the University Medicine Group Practice Anticoagulation Clinic (University of Colorado, Denver, CO, USA) and costs (

Quality-of-Life Weights for the US Population Self-Reported Health Status and Priority Health Conditions, by Demographic Characteristics

US; 2004 values) included were for warfarin and aspirin (acetylsalicylic acid) use and those associated with major bleeding, treatment of primary events, routine INR and biochemistry monitoring, ECGs, and clinic visits. Costs and outcomes were discounted by 3% per annum.ResultsThe anticoagulation management service improved effectiveness by 0.057 (95% credible interval 0, 0.36) QALYs and reduced costs by

Gender differences in diabetes mellitus and effectson self-care activity

US2100 (95% credible interval −

The effect of obesity and cardiometabolic risk factors on expenditures and productivity in the United States.

US19 800,

Economic evaluation of sustained sedation/analgesia in the intensive care unit.

US300) [2004 values] compared with usual care. Results were sensitive to the extent of the increase in risk of primary events (all strokes and systemic embolic events attributable to usual care, but were robust to variation in other input variables). The anticoagulation management service was the dominant strategy in 91% of Monte Carlo simulations.ConclusionThe anticoagulation management service appears to cost less and provide greater effectiveness than usual care. To enhance stroke prophylaxis among high-risk patients with atrial fibrillation, physicians and Medicare plans may wish to consider augmenting ‘usual care’ by the addition of patient-monitoring technology strategies such as formally organised anticoagulation monitoring programmes.

Prevalence of multiple cardiac risk factors in US adults with diabetes

Background:Many of the large ongoing national surveys of the US population contain a question that asks for the respondents self-reported health status: “excellent,” “very good,” “good,” “fair,” or “poor.” These surveys could be used to conduct cost-utility analyses of health care policies, treatments or other interventions if quality-of-life (QOL) weights for the self-reported health statuses were also available. Objective:The objective of this study was to produce nationally representative QOL weights for self-reported health status and for 10 “priority” health conditions, by a series of demographic variables. Research Design:The Medical Expenditure Panel Survey contains the questions from the EQ-5D health status measure. A recent study has calculated time-trade-off-derived QOL weights corresponding to the EQ-5D health states for a large sample of Americans. We use these data to construct QOL weights for the 5 self-reported health status categories and 10 priority health conditions, by a series of demographic variables. Results:Mean and median QOL weights were produced for self-reported health status, the 10 priority health conditions, and the demographic variables. We also report mean QOL weights for the self-reported health state and priority health conditions, by the demographic variables. Finally, ordinary least squares and censored least absolute deviation regression equations were used to estimate adjusted QOL weights for these variables. Conclusions:By providing nationally representative QOL weights for self-reported health status and 10 priority health conditions, by demographic variable, we have facilitated the use of large national surveys for conducting cost-utility analysis and increased their value to researchers and policy makers.

Productivity costs associated with cardiometabolic risk factor clusters in the United States.

BACKGROUND Effective self-care, including adherence to diet, exercise, and medication regimens, is an essential component of health care for individuals with diabetes mellitus (DM). OBJECTIVE The goals of this study were to examine sex-based differences in DM and to explore the effects of gender on self-care. METHODS This study was conducted retrospectively using data from the 2001 Medical Expenditure Panel Survey (MEPS). People with DM were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code; analyses were stratified by sex. Variables included age, race/ethnicity, education, income, body mass index (BMI), number of comorbidities, physical and cognitive limitations, smoking status, and depression. Outcome measures were assessed by Short Form-12 (SF-12) Mental Component Summary (MCS) and Physical Component Summary (PCS) scores. Univariate analyses were determined using t, chi(2), or Fisher exact tests, as appropriate. Multivariate analyses examined associations between sex and SF-12 MCS/PCS scores adjusted for other variables. RESULTS A total of 1653 MEPS respondents (883 women, 770 men) with DM were identified for the current study. The women were significantly older than the men (61.2 vs 59.1 years), had less education (11.1 vs 12.0 years), and had lower incomes. Women had higher calculated BMI (31.4 vs 30.3), more comorbidities (7.8 vs 6.4), more depression, and more physical and cognitive limitations than did men. Women also scored lower than men on the SF-12 MCS and PCS (47.8 vs 49.9 and 38.2 vs 41.4, respectively). All these measures were statistically significant (P < 0.01). In multivariate analyses, physical limitations, BMI, and number of comorbidities were negatively correlated, and income and education were positively correlated, with MCS and PCS scores. CONCLUSIONS Compared with their male counterparts, diabetic women scored lower on measures of health status and functioning-factors that are likely to affect self-care activities. Sex-based differences should be considered when developing screening and treatment programs for people with DM.

Cardiovascular Risk Factor Clusters and Employment in the United States

Objective: To examine the effect of obesity and cardiometabolic risk factors on medical expenditures and missed work days.

Managed care's response to a pharmacoeconomic model of serotonin reuptake inhibitors

Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.

Iconographies supplémentaires de l'article : Measuring the effect of asthma control on exacerbations and health resource use

ABSTRACT Purpose: The National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) included diabetes mellitus (DM) as a risk factor for major coronary events equivalent to existing coronary heart disease (CHD). This study estimates the national prevalence of additional CHD risk factors for US adults with and without DM and heart disease using Medical Expenditure Panel Survey (MEPS) data. Methods: In this retrospective study using nationally representative 2000 and 2002 MEPS survey data, DM and CHD for adult respondents (n = 44 481) were identified by ICD-9 codes or self-reported DM, coronary heart disease, angina, heart attack or stroke, or other heart disease. Six additional risk factors assessed were hypertension, hypercholesterolemia, smoking, age (≥ 45 years [men], ≥ 55 years [women]), obesity, and physical inactivity. The national prevalence of cardiac risk factors was assessed in four subgroups: CHD–/DM–; CHD–/DM+; CHD+/DM–, CHD+/DM+. Results: The CHD–/DM+ group had significantly higher mean risk factor counts than did the CHD–/DM– group and the CHD+/DM– group (2.6 versus 1.4 and 2.4, respectively; both p < 0.01). The CHD+/DM+ group had the highest mean risk factor count at 3.4. Proportions of US adults in each subgroup with two or more risk factors were CHD–/DM–: 39.5%; CHD–/DM+: 81.9%; CHD+/DM–: 74.9%; CHD+/DM+: 95.1%. Limitations of this study include the use of self-reported data and the lack of data regarding family history of CHD, both of which are likely to result in conservative prevalence estimates. Conclusion: Results presented here indicate that diabetes, with or without co-morbid heart disease, is associated with a high prevalence of cardiac risk factors in US adults. The prevalence estimates reported here demonstrate the extensiveness of this public health issue. It is essential that medical providers treat modifiable risk factors in patients with diabetes aggressively with lifestyle modifications and pharmacotherapy consistent with NCEP ATP III recommendations.