Patient experience of telephone consultations in gynaecology: a service evaluation.

OBJECTIVE: To investigate patient perspective of telephone consultations (TCs) in gynaecology and identify which patients benefit most from a telemedicine system. DESIGN: Service evaluation. SETTING: Gynaecology outpatient services at a tertiary referral hospital. POPULATION: Patients who received a TC during May and June 2020. METHODS: Postal questionnaire combining three validated tools: QQ-10, Patient Enablement Index (PEI) and National Health Service Friends and Family Test (NHS-FFT). Quantitative data and free text responses were analysed. MAIN OUTCOME MEASURES: Responses to QQ-10, PEI and NHS-FFT. RESULTS: In total, 1307 patients were contacted and 504 patients responded (39%). Most (89%) described their experience as 'Very good' or 'Good' (NHS-FFT). Positive themes from responses included 'convenience', 'effectiveness' and 'equivalent care'. QQ-10 responses demonstrated a high Value score of 79 (0-100) and a low Burden score of 15. PEI scores suggested that most patients felt better or much better able to understand and cope with their condition following TC. The majority of patients (77%) would 'Strongly agree' or 'Mostly agree' to a repeat TC. Regarding patient outcomes, 21% were discharged and 71% required follow up. Menopause, fertility and endometriosis follow-up clinic patients benefited most from TC. Gynaecology-oncology patients found TC least acceptable. CONCLUSION: We report a large questionnaire survey of patient experience of TC in gynaecology. Telemedicine is convenient, acceptable and effective for conducting care in selected groups. TC can support patients in communicating intimate symptoms. TWEETABLE ABSTRACT: Telephone consultations are a convenient, acceptable and effective medium for conducting patient care in gynaecology.

Risk stratification, treatment selection, and transplant eligibility in multiple myeloma: a qualitative study of the perspectives and self-reported practices of oncologists.

BACKGROUND: Since the early 2000s, treatment options for multiple myeloma have rapidly expanded, adding significant complexity to the management of this disease. To our knowledge, no systematic qualitative research on clinical decision-making in multiple myeloma has been published. We sought to characterize how physicians view and implement guidelines and incorporate novel approaches into patient care. METHODS: We designed a semi-structured qualitative interview guide informed by literature review and an expert advisory panel. We conducted 60-minute interviews with a diverse sample of oncology physicians in the southeast United States. We used a constant comparative method to code and analyze interview transcripts. The research team and advisory panel discussed and validated emergent themes. RESULTS: Participants were 13 oncologists representing 5 academic and 4 community practices. Academic physicians reported using formal risk-stratification schemas; community physicians typically did not. Physicians also described differences in eligibility criteria for transplantation; community physicians emphasized distance, social support, and psychosocial capacity in making decisions about transplantation referral; the academic physicians reported using more specific clinical criteria. All physicians reported using a maintenance strategy both for post-transplant and for transplant-ineligible patients; however, determining the timing of maintenance therapy initiation and the response were reported as challenging, as was recognition or definition of relapse, especially in terms of when treatment re-initiation is indicated. CONCLUSIONS: Practices reported by both academic and community physicians suggest opportunities for interventions to improve patient care and outcomes through optimal multiple myeloma management and therapy selection. Community physicians in particular might benefit from targeted education interventions about risk stratification, transplant eligibility, and novel therapies.

Issues in blood pressure control and the potential role of single-pill combination therapies.

Hypertension (HTN) is a major risk factor for cardiovascular mortality, yet only a small proportion of hypertensive individuals receive appropriate therapy and achieve target blood pressure (BP) values. Factors influencing the success of antihypertensive therapy include physicians' acceptance of guideline BP targets, the efficacy and tolerability of the drug regimen, and patient compliance and persistence with therapy. It is now well recognised that most hypertensive patients require at least two antihypertensive agents to achieve their target BP. However, complicated treatment regimens are a major contributory factor to poor patient compliance. The use of combination therapy for HTN offers a number of advantages over the use of monotherapy, including improved efficacy, as drug combinations with a synergistic mechanism of action can be used. This additive effect means that lower doses of the individual components can be used, which may translate into a decreased likelihood of adverse events. The use of single-pill combination therapy, in which two or more agents are combined in a single dosage form, offers all the benefits of free combination therapy (improved efficacy and tolerability over monotherapy) together with the added benefit of improved patient compliance because of the simplified treatment regimen. The use of single-pill combination therapy may also be associated with cost savings compared with the use of free combinations for reasons of cheaper drug costs, fewer physician visits and fewer hospitalisations for uncontrolled HTN and cardiovascular events. Thus, the use of single-pill combination therapy for HTN should help improve BP goal attainment through improved patient compliance, leading to reduced costs for cardiovascular-related care.

The design of an observational study of hypertension management, adherence and pressure control in Blood Pressure Success Zone Program participants.

AIMS: The Blood Pressure Success Zone (BPSZ) Program, a nationwide initiative, provides education in addition to a complimentary trial of one of three antihypertensive medications. The BPSZ Longitudinal Observational Study of Success (BPSZ-BLISS) aims to evaluate blood pressure (BP) control, adherence, persistence and patient satisfaction in a representative subset of BPSZ Program participants. The BPSZ-BLISS study design is described here. METHODS: A total of 20,000 physicians were invited to participate in the study. Using a call centre supported Interactive Voice Response System (IVRS), physicians report BP and other data at enrolment and every usual care visit up to 12 +/- 2 months; subjects self-report BPs, persistence, adherence and treatment satisfaction at 3, 6 and 12 months post-BPSZ Program enrolment. In addition to BPSZ Program enrolment medications, physicians prescribe antihypertensive medications and schedule visits as per usual care. The General Electric Healthcare database will be used as an external reference. RESULTS: After 18 months, over 700 IRB approved physicians consented and enrolled 10,067 eligible subjects (48% male; mean age 56 years; 27% newly diagnosed); 97% of physicians and 78% of subjects successfully entered IVRS enrolment data. Automated IVRS validations have maintained data quality (< 5% error on key variables). Enrolment was closed 30 April 2007; study completion is scheduled for June 2008. CONCLUSIONS: The evaluation of large-scale health education programmes requires innovative methodologies and data management and quality control processes. The BPSZ-BLISS design can provide insights into the conceptualisation and planning of similar studies.

The economic consequences of noncompliance in cardiovascular disease and related conditions: a literature review.

OBJECTIVES: To review studies on the cost consequences of compliance and/or persistence in cardiovascular disease (CVD) and related conditions (hypertension, dyslipidaemia, diabetes and heart failure) published since 1995, and to evaluate the effects of noncompliance on healthcare expenditure and the cost-effectiveness of pharmaceutical interventions. METHODS: English language papers published between January 1995 and February 2007 that examined compliance/persistence with medication for CVD or related conditions, provided an economic evaluation of pharmacological interventions or cost analysis, and quantified the cost consequences of noncompliance, were identified through database searches. The cost consequences of noncompliance were compared across studies descriptively. RESULTS: Of the 23 studies identified, 10 focused on hypertension, seven on diabetes, one on dyslipidaemia, one on coronary heart disease, one on heart failure and three covered multiple diseases. In studies assessing drug costs only, increased compliance/persistence led to increased drug costs. However, increased compliance/persistence increased the effectiveness of treatment, leading to a decrease in medical events and non-drug costs. This offset the higher drug costs, leading to savings in overall treatment costs. In studies evaluating the effect of compliance/persistence on the cost-effectiveness of pharmacological interventions, increased compliance/persistence appeared to reduce cost-effectiveness ratios, but the extent of this effect was not quantified. CONCLUSIONS: Noncompliance with cardiovascular and antidiabetic medication is a significant problem. Increased compliance/persistence leads to increased drug costs, but these are offset by reduced non-drug costs, leading to overall cost savings. The effect of noncompliance on the cost-effectiveness of pharmacological interventions is inconclusive and further research is needed to resolve the issue.

Optimization of process variables for minimization of byproduct formation during fermentation of blackstrap molasses to ethanol at industrial scale.

AIMS: To investigate the effect of molasses concentration, initial pH of molasses medium, and inoculum's size to maximize ethanol and minimize methanol, fusel alcohols, acetic acid and aldehydes in the fermentation mash in industrial fermentors. METHODS AND RESULTS: Initial studies to optimize temperature, nitrogen source, phosphorous source, sulfur supplement and minerals were performed. The essential nutrients were urea (2 kg in 60 m(3)), 0.5 l each of commercial phosphoric acid and sulfuric acid (for pH control) added at the inoculum preparation stage only. Yields of ethanol, methanol, fusel alcohols, total acids and aldehydes per 100-l fermentation broth were monitored. Molasses at 29 degrees Brix (degree of dissolved sugars in water), initial pH 4.5, inoculum size 30% (v/v) and anaerobic fermentation supported maximum ethanol (7.8%) with Y(P/S) = 238 l ethanol per tonne molasses (96.5% yield) (8.2% increase in yield), and had significantly lower values of byproducts than those in control experiments. CONCLUSIONS: Optimization of process variables resulted in higher ethanol yield (8.2%) and reduced yield of methanol, fusel alcohols, acids and aldehydes. SIGNIFICANCE AND IMPACT OF THE STUDY: More than 5% substrate is converted into byproducts. Eliminating or reducing their formation can increase ethanol yield by Saccharomyces cerevisiae, decrease the overall cost of fermentation process and improve the quality of ethanol.

The significance of compliance and persistence in the treatment of diabetes, hypertension and dyslipidaemia: a review.

OBJECTIVES: To review studies of patient compliance/persistence with cardiovascular or antidiabetic medication published since the year 2000; to compare the methods used to measure compliance/persistence across studies; to compare reported compliance/persistence rates across therapeutic classes and to assess whether compliance/persistence correlates with clinical outcomes. METHODS: English language papers published between January 2000 and November 2005 investigating patient compliance/persistence with cardiovascular or antidiabetic medication were identified through searches of the MEDLINE and EMBASE databases. Definitions and measurements of compliance/persistence were compared across therapeutic areas using contingency tables. RESULTS: Of the 139 studies analysed, 32% focused on hypertension, 27% on diabetes and 13% on dyslipidaemia. The remainder covered coronary heart disease and cardiovascular disease (CVD) in general. The most frequently reported measure of compliance was the 12-month medication possession ratio (MPR). The overall mean MPR was 72%, and the MPR did not differ significantly between treatment classes (range: 67-76%). The average proportion of patients with an MPR of >80% was 59% overall, 64% for antihypertensives, 58% for oral antidiabetics, 51% for lipid-lowering agents and 69% in studies of multiple treatments, again with no significant difference between treatment classes. The average 12-month persistence rate was 63% and was similar across therapeutic classes. Good compliance had a positive effect on outcome in 73% of the studies examining clinical outcomes. CONCLUSIONS: Non-compliance with cardiovascular and antidiabetic medication is a significant problem, with around 30% of days 'on therapy' not covered by medication and only 59% of patients taking medication for more than 80% of their days 'on therapy' in a year. Good compliance has a positive effect on clinical outcome, suggesting that the management of CVD may be improved by improving patient compliance.

Risk of chronic kidney disease in hypertensive patients with other metabolic conditions.

Using a retrospective cohort design and electronic medical records, we examined chronic kidney disease (CKD) risk over a 6-year period among hypertensive patients in relation to the presence of diabetes, hyperlipidaemia and/or high body mass index. After adjusting for age, sex, smoking status and baseline glomerular filtration rate (GFR), hypertensive patients without other metabolic risk factors had a relative risk of CKD (versus normotensive patients) of 2.0 (95% CI 1.8-2.2); hypertensive patients with other metabolic conditions had adjusted relative risks ranging from 2.4 to 2.6 for those without comorbid diabetes, and from 3.3 to 5.5 for those with comorbid diabetes. Our study thus confirms prior research demonstrating elevated CKD risk in hypertensive patients, and suggests that this risk varies substantially in relation to other metabolic conditions, especially diabetes.

Risk of diabetes in a real-world setting among patients initiating antihypertensive therapy with valsartan or amlodipine.

In the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial, the risk of new-onset diabetes was reported to be 23% lower among patients initiating therapy with valsartan versus amlodipine. The objective of our study was to examine whether this finding is generalizable to 'real-world' clinical practice. A retrospective cohort design and a large US health insurance database were employed for analyses. Study subjects included all hypertensive patients, aged >or=35 years, who were free from diabetes and who initiated treatment with valsartan (n=9999) or amlodipine (n=18 698) between January 1999 and March 2005. Unadjusted absolute risks of diabetes were 21.4 (95% confidence interval (CI) 18.9-24.3) and 26.3 (95% CI 24.3-28.3) per 1000 patient-years for valsartan and amlodipine, respectively; the corresponding relative risk (RR) for valsartan was 0.82 (95% CI 0.70-0.94). Multivariate analyses - controlling for age, sex, presence of hypercholesterolemia, cardiovascular disease and kidney disease, and pretreatment medical care expenditures - yielded similar results (RR=0.79, 95% CI 0.68-0.92). Our study thus corroborates the finding from VALUE that diabetes risk is lower for patients who receive valsartan versus amlodipine, and extends this finding to a 'real-world' setting.

Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre.

OBJECTIVE: Anastomotic leak post-gastro-esophagectomy for esophageal carcinoma remains an important issue in immediate as well as late morbidity and mortality. Several predictive factors such as patient and technical variables have been suggested with inconsistent findings. Our aim was to compare these factors and the results of treatment of anastomotic dehiscence on short and longterm survival in our center to published data. METHODS: A retrospective study of 276 consecutive patients post-Ivor-Lewis gastro-esophagogastrectomy for esophageal carcinoma between 1992 and 1999. Explanatory variables taken into account for predicting anastomotic leak included preoperative weight loss, neoadjuvant therapy, inkwelling of the anastomosis, gastric drainage procedure and involvement of longitudinal resection margins. Incidence variation over time was compared. 5-year survival was assessed using the Kaplan-Meier method. RESULTS: The anastomotic leak rate was 5.1% with only minor variation over time. The 30-day mortality with anastomotic leak was 35.7% compared to 4.2% for patients without leak (P<0.05). None of the suggested explanatory variables analyzed reached statistical significance at a 5% level. On multiple logistic regression there was a trend towards gastric outlet drainage procedure which might decrease the relative risk by 61% (P=0.099). After excluding the 30-day mortality the 5-year survival with anastomotic leak was not different to those without. CONCLUSIONS: None of the factors reported in the literature reached statistical significance in our series. High institutional and high surgeon volume seem to outweigh any other contributing factor. Aggressive management for substantial leaks is advocated by the authors as long term palliation does not seem to be affected once the leak has been successfully treated.

Quality of life in geriatric depression: a comparison of remitters, partial responders, and nonresponders.

The authors examined patterns of improvement in quality of life (QOL) in elderly patients with recurrent major depression (MDD) after acute treatment. One hundred elderly (age 60-88 years) patients with recurrent MDD were randomized to receive either bupropion sustained-release (100 mg-300 mg/day) or paroxetine (10 mg-40 mg/day) for 6 weeks. Treatment with both paroxetine and bupropion was associated with improvements in QOL. Lower perceived Physical- and Social-Functioning QOL ratings at baseline were associated with lower treatment response. Improvement in depression symptom ratings correlated significantly with improvement in QOL on many domains, but accounted for less than one-quarter of the total variance. Remitters showed significantly (P<0.001) greater improvement than both Partial Responders and Nonresponders on various measures. Findings support the importance of treating elderly depressed patients to full remission to maximize impact on both emotional and physical QOL domains.

Retrospective analysis of the health-care costs of bupropion sustained release in comparison with other antidepressants.

OBJECTIVE: The objective of this study was to evaluate the health care costs associated with the treatment of a new episode of depression with bupropion sustained release (SR) rather than with other antidepressants (selective serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs], and serotonin norepinephrine reuptake inhibitors [SNRIs]). METHODS: This was a retrospective cohort study based on the private-pay, fee-for-service 1997 and 1998 MEDSTAT MarketScan databases. Individuals were included if they were 18 years of age or older, had an initial prescription for an antidepressant under study with an index prescription date between July 1997 and June 1998, and had a claim for a diagnosis of depression diagnosis within 30 days of the index date. All patients' claims from six months before and after receiving their index antidepressant prescription were examined. Total, outpatient, and pharmacy costs were compared among antidepressant groups using an intent-to-treat analysis with exponential regression models and bootstrapped 95% confidence intervals. RESULTS: A total of 1771 patients were included in the study cohort. The mean age was 41.6 years, and 69.5% of subjects were female. Most patients (75%) continued with the index antidepressant during the 6-month follow-up period. Although the drug acquisition cost was lowest for TCAs, total costs were significantly higher for patients treated with TCAs than for those treated with bupropion SR (p < .05). In comparison with bupropion SR, patients initiating therapy with sertraline had significantly higher mental health payments (p < .05). CONCLUSIONS: Initiating treatment of depression with bupropion SR was associated with lower total mental health care costs compared with TCAs and with sertraline. This study reaffirms that formulary and medical decision-makers should consider the overall impact of antidepressant treatment, including but not limited to drug acquisition costs, other health care costs, and drug efficacy and safety.

Impact of smoking status on workplace absenteeism and productivity.

OBJECTIVES: To: evaluate the impact of smoking status on objective productivity and absenteeism measures; evaluate the impact of smoking status on subjective measures of productivity; and assess the correlation between subjective and objective productivity measures. DESIGN: Prospective cohort study in a workplace environment. SUBJECTS: Approximately 300 employees (100 each of former, current, and never smokers) at a reservation office of a large US airline. MAIN OUTCOME MEASURES: Objective productivity and absenteeism data were supplied by the employer. Subjective assessments of productivity were collected using a self report instrument, the Health and Work Questionnaire (HWQ). RESULTS: Current smokers had significantly greater absenteeism than did never smokers, with former smokers having intermediate values; among former smokers, absenteeism showed a significant decline with years following cessation. Former smokers showed an increase in seven of 10 objective productivity measures as compared to current smokers, with a mean increase of 4.5%. While objective productivity measures for former smokers decreased compared to measures for current smokers during the first year following cessation, values for former smokers were greater than those for current smokers by 1-4 years following cessation. Subjective assessments of "productivity evaluation by others" and "personal life satisfaction" showed significant trends with highest values for never smokers, lowest for current smokers, and intermediate for former smokers. CONCLUSIONS: Workplace productivity is increased and absenteeism is decreased among former smokers as compared to current smokers. Productivity among former smokers increases over time toward values seen among never smokers. Subjective measures of productivity provide indications of novel ways of productivity assessment that are sensitive to smoking status.

Economic burden of influenza-like illness in long-term-care facilities.

Direct medical costs and medically related transportation costs incurred by patients in long-term-care facilities (LTCFs) as a result of influenza-like illness (ILI) were studied. The study was conducted from the payer's perspective. Charts were reviewed retrospectively for all patients who were residents of four Richmond, Virginia, LTCFs between January 1 and May 31, 1999. Consultant pharmacists gathered data on patient demographics, ILI status, vaccination for influenza and streptococcal pneumonia, diagnosis of asthma or chronic obstructive pulmonary disease, and utilization of health care services related to ILI. Services included the use of antimicrobials, antivirals, and respiratory drugs; emergency room visits; diagnostic tests; hospitalizations; and medically related transportation. Costs were based on average wholesale prices (for drugs) and Medicare or Medicaid reimbursement rates. Data were collected for 551 patients. Of these, 112 patients had been diagnosed with 128 cases of ILI during the study period. Twenty-two patients with ILI had 28 visits to emergency rooms, and 30 patients with ILI had 36 hospitalizations. The mean +/- S.D. cost per case of ILI was $1341 +/- $2063; inpatient hospital costs accounted for 84% of this amount. Centers for Disease Control and Prevention criteria for ILI provided a lower incidence of ILI and, consequently, a lower mean +/- S.D. cost of $968 +/- $1806 per case. ILI in patients in four LTCFs in Richmond, Virginia, generated substantial costs, the bulk of which resulted from hospitalization. A substantial percentage of the patients apparently were not immunized.

Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs.

The development and application of an economic model designed to assess the specific costs and benefits of health plan coverage of smoking-cessation programs involving sustained-release bupropion hydrochloride are described. A cohort of 100,000 employees or health plan members and 60,000 adult dependents was followed from the start of the model to either retirement at age 65 or death at age 85. The model was used to compare outcomes for coverage versus no coverage of sustained-release bupropion hydrochloride as a component of a smoking-cessation benefit under four managed care plan scenarios and four employer scenarios. For the managed care scenarios involving coverage of bupropion sustained-release the overall decrease in health care costs over a 20-year period ranged from $7.9 million to $8.8 million; for every dollar spent covering smoking cessation, $4.10-$4.69 in health care costs was saved. For the employer scenarios, health care costs over 20 years decreased by $8.3 million to $14.0 million, and smoking-related indirect costs decreased an additional $5.1 million to $7.7 million; for every dollar spent covering smoking cessation, $5.04-$6.48 was saved. A model developed to assess the specific costs and benefits of covering sustained release bupropion hydrochloride as a component of a smoking-cessation benefit indicated cost savings for health plans and employers.

Cost associated with the treatment of influenza in a managed care setting.

OBJECTIVE: The purpose of this study was to assess the costs and treatments associated with influenza patients with and without secondary viral or bacterial infections in a managed care setting. METHODS: Patients with influenza diagnoses (ICD-9 = 487) were identified in the PharMetrics database between January 1, 1997 and June 30, 1998. Patients were placed into 3 cohorts: influenza only (INF), influenza plus a secondary bacterial respiratory infection (BRI), and influenza plus a secondary viral respiratory infection (VRI). The index date was defined as the date of the first occurrence of an influenza diagnosis during the study period. Medical claims were assessed from the index date to the end of the influenza episode, which was defined as the date of the last claim for influenza followed by a 90-day "clean period" during which no influenza-related charges occurred. RESULTS: A total of 18,000 patients met the inclusion criteria. The mean age was 29 years, and 54% were female. Approximately 93% of patients were placed in the INF cohort, and 3% each in the BRI and VRI groups. The BRI cohort had the highest mean total cost ($5593* SD = 10,939), compared with the VRI cohort ($847 SD = 1782) and INF cohort ($602 SD = 2813) (P less than.0001 vs INF; P less than.0001 vs VRI). This total cost disparity was primarily driven by differences in inpatient costs: BRI ($3509, SD = 9474); VRI ($208, SD = 1327); INF ($138, SD = 2145). Patients in the BRI cohort averaged 0.5 hospitalizations per patient vs 0.06 in the VRI cohort and 0.03 in the INF cohort. CONCLUSIONS: Subjects in the BRI cohort were significantly more costly and had an increased risk of hospitalization as compared with subjects in the VRI or INF cohorts. Early intervention with antiviral agents and/or antibiotics, where appropriate, could result in significant cost savings for managed care organizations.

Fax technology for collecting outcomes data in a computer database.

In this era of cost containment, outcomes research is becoming more prevalent. Therefore, various technologies allowing for flexibility in study design and the capture of specific clinical information need to be examined and used. These technologies include fax data systems, pocket scanners, automated telephone equipment, and hand-held computer devices. Fax data systems convert a fax machine into an automated data-entry system. Data-filled forms are faxed to a computer, the fax is converted, and the data are entered into preset fields in a database. Applications for fax systems include acute care-based and ambulatory care-based drug-use evaluations, drug recall systems, and patient-completed surveys of health status. Pocket scanners are hand-held instruments for rapid data entry and transport. Applications for pocket scanning include patient interview responses, procedure and disease analysis, and procedure coding. Options for automated telephone equipment include surveys with interactive voice-mail responses or keypad data entry, pharmacist-monitored drug information and survey services, fax-back and mail-out services, and patient-generated disease intervention programs. Hand-held computer technology is a source of information on multiple protocols and care pathways. All these technologies improve data collection with respect to accuracy and speed, facilitate data analysis, and promote cost-efficient information sharing. The purpose of this study was to evaluate the use of fax technology in data collection for a prospective, multicenter study of the outcomes and cost-effectiveness of two drugs used in the treatment of cancer. Details for the pharmacoeconomic study can be found elsewhere. Fax technology was selected because of the ease with which those responsible for managing the data collection could be trained to use it, the affordability and efficiency of the technology, the ease with which data could be analyzed, and the accuracy of data collection.