Peter Davey

Pharmacoeconomics of intravenous drug administration.

SummaryDirect administration of a drug into a vein guarantees bioavailability, i.e. the total amount of drug is fully available to the bloodstream for transport to all areas of the body. What is not ensured is the safety, need and ‘Value for money’ of this route. Few workers would disagree that there is increased morbidity associated with this method of administration. Adverse events range from the painful irritation of veins to life-threatening infection introduced by needle puncture. It is proposed that in many situations the disadvantages of the intravenous (IV) route outweigh the advantages.There are many hidden costs of IV therapy ranging from the adverse events associated with IV administration to the need for specialised equipment, consumables and additional personnel time. Recent studies have shown that the oral route can be substituted in many patients receiving IV therapy without loss of efficacy. The reduction in costs intrinsic to IV therapy is an additional bonus.There is a need to increase the use of alternative routes of administration on the basis of safety, quality of life and cost.

Cost-benefit analysis of cephradine and mezlocillin prophylaxis for abdominal and vaginal hysterectomy

Summary. Four hundred patients (300 abdominal and 100 vaginal hysterectomies) were randomized to receive a single, pre‐operative intravenous injection of saline (placebo), 2 g cephradine or 5 g mezlocillin. The frequency of wound and pelvic infections was significantly reduced (P<0.05, χ2‐ or Fishers exact test) in the abdominal hysterectomy patients who received cephradine (16% vs 23% mezlocillin, 29% placebo) and in the vaginal hysterectomy patients who received cephradine or mezlocillin (0% mezlocillin, 6% cephradine vs 27% placebo). These results are similar to those of previous studies and suggest that prophylaxis is more effective for vaginal than for abdominal hysterectomy. However, a cost‐benefit analysis supported the opposite conclusion. Cephradine prophylaxis for abdominal hysterectomy resulted in cost savings to the hospital and the community health services with measurable benefits to the patient. In contrast, cephradine or mezlocillin prophylaxis for vaginal hysterectomy resulted in increased costs to the hospital, no savings to community services and no significant benefit to the patient. We conclude that cost‐benefit analysis provided valuable additional information to the conventional, statistical analysis of wound or pelvic infection rates.

Cost Effectiveness of Once‐Daily Oral Antimicrobial Therapy

Once daily dosing of oral antimicrobials achieves significantly better patient compliance than three or four times daily dosing, and limited data suggest that this is associated with greater efficacy. Comparison of once daily and twice daily dosing is less consistent, and most studies show only marginally better compliance with once daily dosing versus twice daily dosing. Detection of urinary antimicrobial activity provides a simple method for checking compliance with oral antimicrobials and deserves wider study. Counts of residual tablets have been shown to overestimate compliance. Intravenous formulations are always more expensive than equivalent oral formulations, and preparation and administration of intravenous drugs adds significant additional costs. Moreover, intravenous regimens are complex, and a number of studies have shown that serious errors occur in both preparation and administration of intravenous drugs. There is increasing evidence that serious infections can be adequately treated with oral drugs, and the excellent bioavailability of quinolones makes them particularly attractive for these indications. Clinicians require a method for checking absorption by patients with severe infection, and the Serum Bactericidal Test may provide a practical method for monitoring a wide variety of drugs.

Sequential antibiotic therapy: the right patient, the right time and the right outcome

The aim of sequential therapy should be to provide better quality of care at lower cost. In comparison with i.v. therapy, oral administration is safer, more acceptable to the patient, facilitates early discharge from hospital and reduces the cost of consumables. However, if given to the wrong patient, oral antimicrobial therapy could both increase the cost and reduce the quality of care, either because of ineffective treatment, or unnecessary prolongation of treatment. Hospitals must develop policies for sequential therapy which define standards against which clinical care can be audited. The standards will need to be revised as new data become available from local audit and from research. Further research on sequential therapy is undoubtedly required, with particular emphasis on the reliability of absorption of oral drugs by hospitalized patients.

The cost effectiveness of amoxicillin/clavulanic acid as antibacterial prophylaxis in abdominal and gynaecological surgery.

SummaryThe objective of this study was to compare the cost effectiveness of amoxicillin/clavulanic acid with other antibacterial regimens for prophylaxis of infection after elective abdominal or gynaecological surgery. Data from 21 previously published comparative clinical trials were used to calculate statistical confidence intervals for differences in postoperative wound infection rate. A simple model was used to produce a tabular sensitivity analysis of cost effectiveness over a wide range of costs of wound infection and potential differences in efficacy. For more expensive comparator regimens, including combination regimens utilising gentamicin and metronidazole, amoxicillin/clavulanic acid was either likely to be more cost effective or equally cost effective. For example, in trials of colonic surgery the comparators were on average £11.39 more expensive than amoxicillin/clavulanic acid, which was >95% likely to be more cost effective unless the cost of wound infection was estimated to be >£1519.Amoxicillin/clavulanic acid was more expensive than only 2 of the 21 comparators. Furthermore, in one of these 2 trials it was also significantly more effective than the comparator. In this trial, amoxicillin/clavulanic acid was >95% likely to be more cost effective as prophylaxis in hysterectomy than rectal metronidazole, provided that the cost of wound infection was estimated to be >£179. In conclusion, this analysis shows that amoxicillin/clavulanic acid, given as monotherapy, is likely to be equally or more cost effective than a wide range of comparator regimens for prophylaxis of elective abdominal or gynaecological surgery.n

The doctor-patient relationship and prescribing patterns. A view from primary care.

AbstractThe doctor-patient relationship has been described in economic terms as an ‘agency relationship’ where informed agents make decisions for uninformed clients. However, the decision to prescribe and the decision to accept the prescription by the patient are more complex in nature and involve many variables. Other factors, such as the ‘need’ for the prescription and the disease state (acute or chronic) also influence prescribing practice. Communication between the physician and patient was found to be important for rational and effective prescribing. The client can make better decisions with the relevant information, thus breaking down the agency relationship that once existed.n

Costs Associated with Symptomatic Systolic Heart Failure

AbstractObjective: To investigate whether the extent of systolic dysfunction is a useful predictor of the costs of healthcare and social support for patients with heart failure.n Design: Cross-sectional study with collection of cost data attributed to management of heart failure in the previous year.n Setting: Four primary-care practices in Scotland.n Patients: Patients receiving long term therapy with loop diuretics for suspected heart failure.n Interventions: Two-dimensional and Doppler echocardiography.n Main outcome measures and results: Two hypotheses were tested: (i) the proportion of patients incurring costs is higher in patients with abnormal left ventricular (LV) function; and (ii) the median cost per patient that incurs costs is higher in patients with abnormal LV function.Of the 226 patients in the study, 67 (30%) had abnormal systolic function. In comparison with the remaining 159 patients, they had higher healthcare costs [£560 vs £440 per patient year (1994/1995 values)], were more likely to incur hospital inpatient or outpatient costs [Odds ratio (OR): 2.02; 95% confidence interval (CI): 1.06 to 3.84] and had significantly higher primary-care costs (mean £292 vs £231 per patient year; p = 0.02, Mann Whitney test). In contrast, they were no more likely to incur social support costs (OR: 1.22; 95% CI: 0.52 to 2.86) and the mean cost of social support per patient year was lower (£234 vs £373).n Conclusions: Patients with objectively measured systolic dysfunction incurred significantly higher healthcare costs in the year before diagnosis. This suggests that treatment that improves systolic function will reduce healthcare costs, even in a primary-care population with relatively mild congestive heart failure.n

Once-Daily Aminoglycoside Administration in Gram–Negative Sepsis

SummaryA fuller understanding of the pharmacodynamics of aminoglycoside antibiotics now exists compared with when they were introduced. Recent findings have shown that once-daily dosage regimens of aminoglycosides are as effective as bd or tid regimens in the Treatment of Gram-negative sepsis. However, radical changes in dosage frequency based on this knowledge are resisted by some physicians because of fears about the peak concentration Toxicity of aminoglycosides These fears have been shown to be misplaced. The delay in the translation of research findings into practice may be attributable to the sheer quantity of medical literature and the limited time that clinicians have available to read it.Because healthcare resources are finite, physicians arc increasingly becoming aware of the need to use drug therapy in the most cost-effective way. An important component of amino glycoside therapy that may persuade clinicians to change their practice is the organised consideration of the various costs associated with different administration regimens. This review examines the source of those costs, and endorses once-daily dosage of aminoglycosides from both an economic and practical viewpoint.

Pharmacoeconomics of appropriate antimicrobial use

Pharmacoeconomics is founded on the key principle of economics, which is that societys resources are limited, and therefore, choices have to be made about the use of those resources. Pharmacoeconomic analysis should estimate the costs and consequences of different drug treatments, including the use of all health care resources, not drug costs alone. Application of these principles to appropriate antimicrobial treatment requires separate consideration of a sequence of questions: Who needs treatment? What are the best drug, dose, route of administration, and duration of therapy? What information do we have about the outcomes of treatment? None of these questions is easy to answer, but economic analysis will help the decision maker by making explicit the costs and consequences of the available alternatives.

New antiviral and antifungal drugs.

We thank all the respondents to the survey and the nurses at the Leicestershire Hospice for their interest and willing participation, Dr Carol Jagger for statistical help, and Miss K Jeffery for preparing the typescript. 1 St Christophers Hospice Information Service. 1988 Directory of hospice services. Sydenham: St Christophers Hospice, 1988. 2 Hill F, Oliver C. Hospice ?the cost o? in-patient care. Health Trends 1984;16: 9-11.