Isolating the cost of osteoporosis-related fracture for postmenopausal women. A population-based study.

BACKGROUND: Osteoporosis is a condition that will pose an increasing burden on health systems as populations age. OBJECTIVE: The objective of this study was to estimate the net 'per case' direct medical cost of fracture of indigent women age 50 years or greater and describe the cost of fracture for Medicaid and Medicare payers by inpatient hospital, physician, long-term care, prescription and miscellaneous expenditures. METHODS: This study utilized a quasi-experimental retrospective interrupted time series design to isolate the economic impact of fracture. Administrative claims data for a continuous period of 24 months (12 months prior to fracture and 12 months after fracture) describing the Medicaid and Medicare expenditures for a cohort of women suffering from femur or other fracture in 1993 was abstracted and analyzed. ICD-9CM and CPT-4 codes were used to identify incident cases of fracture. Interrupted time series regression models were estimated using monthly expenditures. RESULTS: A total of 765 Medicaid eligible women 50 years of age or greater experienced a fracture in the base year and met inclusion criteria. Of these, 226 experienced a femur fracture. The time series models detected significant increases in expenditures the month of fracture, however, total Medicaid expenditures returned to baseline trend charge in 7 and 5 months for femur and nonfemur fracture, respectively. Increases in long-term care expenditures persisted throughout the time series, but were offset by reductions in other categories of service. CONCLUSION: The net per case costs of femur and nonfemur fracture are about USD 3,300 and USD 1,300, respectively. The impact of fracture on Medicaid expenditures is temporary as costs rise sharply and return to baseline trend charges within a 12-month period.

Antipsychotic prescription use and costs for persons with schizophrenia in the 1990s: current trends and five year time series forecasts.

Real advances in schizophrenia pharmacotherapy have been made over this decade with the development of more efficacious treatment options with fewer side-effects. These advances have high per-unit direct costs that may have a profound effect on drug budgets of systems caring for persons with schizophrenia. The objective of this study was to describe the changes in utilization and cost for antipsychotic prescriptions by atypical, clozapine, decanoate products, and traditional neuroleptics in a large naturalistic setting, i.e. the Georgia Medicaid population. Secondly, this study forecasted the categorized antipsychotic prescription utilization through the year 2002. Administrative claims data spanning 1990-1997 for Medicaid eligible persons suffering from schizophrenia in the state of Georgia were supplemented with psychiatric institutional data obtained from the Georgia Department of Human Resources. A total of 16227 Medicaid-eligible recipients had a code indicative of schizophrenia (ICD-9-CM=295.(**)) and were at least 16 years of age at the time of their first diagnosis. The mean recipient prescription use and expenditures were tallied for each month of the study and stratified by prescription category (atypical, clozapine, decanoate, and traditional antipsychotic). ARIMA time series models were identified and estimated using these monthly PMPM utilization and expenditures estimates to forecast 5 years beyond the last month of the study. The total use of antipsychotics increased modestly throughout the study period, and the use of atypicals, clozapine, and decanoate products increased substantially, while a decrease was observed for traditional antipsychotics. In 1995 dollars, antipsychotic expenditures increased from a mean of approximately $10 PMPM in 1990 to $95 projected for the year 2002. This transition from traditional oral antipsychotics to atypicals and decanoate products has a profound effect on drug expenditures for systems paying for the care of persons with schizophrenia. Further studies to determine the value of the transitions of therapy described in this study need to be evaluated using a system-wide- or Medicaid perspective.

The net cost of Alzheimer disease and related dementia: a population-based study of Georgia Medicaid recipients.

The objective of this study was to estimate the direct medical cost of Alzheimer disease (AD) and related dementia to the Georgia Medicaid program. A retrospective, cross-sectional, matched control group design was used. AD cases 50 years of age and older were identified by using International Classification of Diseases (9th edition, Clinical Modification) diagnosis codes from 1994 Georgia Medicaid administrative claims files. For every case, three age- and gender-matched non-AD controls were selected. Differences in average recipient Medicaid expenditures between cases and controls were estimated using weighted least squares regression analysis, adjusting for age, gender, race, Charlson comorbidity index, Medicare eligibility, and months of Medicaid eligibility. A total of 8,671 AD cases were identified (prevalence, 4.4%). The average adjusted annual Medicaid expenditure per AD recipient was $14,492 (U.S.). The net (i.e., excess) average annual Medicaid cost per AD recipient (i.e., the difference in adjusted mean expenditures between cases and controls) was estimated to be approximately $8,200. Excessive nursing home expenditures accounted for most of the additional cost of treating dementia (> 85%), although inpatient hospital, physician, outpatient, and prescription drug expenditures also were higher among patients with AD. Based on these estimates, Georgia Medicaid is projected to spend almost $70 million annually for AD and related dementia. The excessive cost attributable to AD poses a significant burden to the Georgia Medicaid program.

Formulary management of low molecular weight heparins.

Low molecular weight heparins (LMWHs) are increasingly being utilised as anticoagulants in healthcare settings. These agents offer several advantages over standard unfractionated heparin. Indications for LMWHs include deep vein thrombosis and pulmonary embolism prophylaxis, deep vein thrombosis treatment, use in coronary procedures associated with a high risk for bleeding, and in acute coronary syndromes. Prior to being added to formularies, LMWHs should be evaluated for efficacy, safety and economic benefits over other anticoagulants. Institutions should be prepared to conduct their own economic assessments in the absence of readily available studies. There is clear evidence that LMWHs are cost saving or are at least cost effective as thromboprophylactic agents in major orthopaedic surgery. The economic benefits of LMWHs in other surgical situations is less clear. Consistent evidence from several countries indicate that LMWHs are cost saving as anticoagulants for the initial treatment of DVT. Further studies are needed to evaluate the efficacy, safety and economics of LMWHs in other conditions besides hip and knee arthroplasty and general surgery.

Persistence with estrogen therapy in a postmenopausal Medicaid population.

We evaluated rates of persistence with estrogen replacement therapy in postmenopausal Georgia Medicaid recipients adjusted for age and race. Data files for 1992-1994 were examined to estimate 3-year conditional survival probabilities using the Kaplan-Meier model, and 3800 subjects were identified. Over 54% of women remained compliant over 29 months, and 17% continued therapy for the entire 35 months of observation. Kaplan-Meier predictors indicated that white women have a 70% chance of being compliant for 3 years, whereas black women have a 60% chance. Monthly discontinuation rates ranged from 1-1.5% after the second month of therapy. Younger, white women were the most likely to maintain and comply with therapy.

The impact of race and fractures on mortality in a postmenopausal Medicaid population.

The purpose of this study was to model fractures and survival by age and race in a large postmenopausal Medicaid population. All Georgia Medicaid claims were abstracted for the years 1992, 1993, and 1994. Claims for postmenopausal women (> or =50 years of age) were retained, and patients with fractures were identified by International Classification of Diseases, Ninth Revision codes for fracture. A survival analysis was conducted using Kaplan-Meier estimators to evaluate the effect of fracture, age, and race on 3-year survival. A total of 159,400 white and black postmenopausal women were identified. The cohort with fracture totaled 5933 patients, with femoral fractures constituting 46% of all fractures. Discounting those with fracture before the study, the fracture incidence was approximately 1.2% in this postmenopausal female cohort. The survival analysis suggested that after age was accounted for, black postmenopausal women had a 42% increased risk of death within 3 years of fracture, compared with 13% for white women. However, postmenopausal black women were approximately 50% less likely to experience a fracture, and postmenopausal black women without fracture had better survival rates than comparable white women. Mortality crossover and the diminished likelihood of fracture mask the true nature of fracture survival in postmenopausal black women. Postmenopausal black women with fracture are at greater risk of dying than their white counterparts.

Health care triage alternatives and the influence of health insurance, education and race.

The relationship between one of Andersen's enabling factors, health insurance status and the choice of a pharmacist as the initial contact in the health care system was examined via telephone surveys. Eighty-seven percent of the sample reported having some form of health insurance. Of all intended health care provider contacts, pharmacists were selected as the initial contact 21% of the time. Logistic regression identified insurance status, education and race as significant (alpha < 0.05) covariates in the model. The odds ratios generated from the logit model indicated that non-whites, persons with less education and no health insurance were more likely to select a pharmacist for triage. The study concluded that uninsured persons were nearly twice as likely to seek pharmacist triage than insured individuals. Pharmacists may be filling an important triage gap for individuals who have limited financial access to traditional sources of physician care.

The ratio of AIDS to non-AIDS Medicaid medical costs from 1992 to 2000.

Our research objective was to calculate and forecast the monthly increase in medical and prescription costs for Medicaid patients with acquired immunodeficiency syndrome (AIDS) and compare these values with costs for non-AIDS patients. A retrospective analysis of AIDS patients and a control group of Georgia Medicaid beneficiaries was conducted between January 1, 1988, and December 31, 1991. AIDS patients were defined using the Keyes algorithm of combinations of International Classification of Diseases, 9th Revision, Clinical Modification codes. The AIDS patient group was matched demographically to a group of non-AIDS patients. Data were adjusted to account for eligibility status, and the ratio of AIDS costs to non-AIDS costs was modeled with an econometric time series procedure. A total of 1966 AIDS patients were identified from 900,000 Medicaid recipients in the study period; 58.0% were male and 59.8% were black. Age was bimodal at < or = 1 year and 33 years. The best fit for the medical cost ratios produced a significant regression coefficient of .37. The initial ratio of AIDS to non-AIDS forecast was 4.25 in January 1992. The January 2000 forecast of this ratio increased to 42.56. This increase equates to an additional $8510.19 per AIDS patient-month for January 2000 in 1991 dollars. The outpatient prescription ratio for AIDS versus non-AIDS patients was not predictable. However, the greatest observed discrepancies were attributed to the expense for antihemophilia products. Overall, the most important finding was the accelerating medical costs for treating AIDS patients compared with costs for treating non-AIDS patients. These results may, in part, reflect additional costs for treating intravenous drug users and pediatric AIDS patients.

Effect of dietary fat content on the bioavailability of a sustained release quinidine gluconate tablet.

Quinidine gluconate 324 mg sustained release tablets (Quinaglute) was administered as a single dose to 15 healthy male subjects following an overnight fast, immediately following a high fat (HF) breakfast or immediately following a low fat (LF) breakfast. Serum samples were obtained over a 48 h period and analyzed for quinidine content using a high performance liquid chromatographic assay. Under the conditions of the study, both the rate and extent of quinidine bioavailability was significantly affected by food. The extent of bioavailability was statistically significantly greater (p less than 0.05) following both the HF and LF meals as compared to that in the fasted state. Rate of bioavailability was significantly enhanced following the LF meal as compared to that of the other two treatment groups. Although peak concentrations were greater and time to peak concentrations somewhat later following the HF meal versus those under fasting conditions, these differences were not statistically significant. In addition, the characteristics of the serum concentration-time profile (as defined by the number, magnitude, and time of occurrence of the multiple absorption maxima) was unique for each of the three treatment groups. Possible mechanisms underlying these results are explored.

Influence of age, sex, and race on prescription drug use among Georgia Medicaid recipients.

Interactions among patients' age, sex, and race that influence prescription drug use in a state Medicaid population are described. A database containing information about all 574,762 Medicaid prescriptions dispensed in Georgia during December 1985 was sorted and summarized so that each record represented one Medicaid recipient. The following data were included for each recipient: the total number of Medicaid prescriptions received by that patient during that month, the total payments made by the state for those prescriptions, and the patient's age, sex, and race. Analyses were conducted on a 10% random sample representing 17,128 patients. The age variable was broken down as follows: Child, 0-5 years; Youth, 6-23 years; Adult, 24-64 years; and Old, 65 years of age or older. Race was recorded as white or nonwhite, and sex as male or female. The average white patient received significantly more prescriptions than did the average nonwhite patient. The largest percentage (41.6%) of the patients in the sample were classified as Old, and this group received the greatest mean number of prescriptions. The differences between mean numbers of prescriptions for white and nonwhite patients increased as the age of the patients increased. Gender influenced drug use only through its interaction with age and race. Patients in the white female Old category had the greatest mean number of prescriptions per patient, and patients in the nonwhite male Youth category had the fewest. The peak period of prescription drug use occurred between the ages of 70 and 80 years, and thereafter use decreased. In this Medicaid population a patient's age and race significantly influenced the number of prescription drugs that he or she used.

A comparative study of current Medicaid prescription reimbursement (MAC/EAC) (maximum allowable cost/estimated acquisition cost) with prescription reimbursement based on a competitive market.

Many pharmacists have suggested that the current Maximum Allowable Cost/Estimated Acquisition Cost (MAC/EAC) program has departed from its intended purpose of generating savings by taking full but fair advantage of the competitive marketplace. The objective of this study was to compare Medicaid prescription reimbursement under current MAC/EAC regulations with prescription reimbursement based on a competitive market. Data representing the top selling single source and multiple source drug products for nine states were analyzed. Results indicated that the current MAC/EAC system of Medicaid reimbursement produced a small savings when compared to reimbursement based on a competitive market.

Estimating demand for health information: pharmacy counseling services.

Consumers want more information about their health care. Before giving more information, health care providers need valid, reliable estimates of the amounts consumers will pay for health information. Using the example of pharmacist counseling services, the authors demonstrate a method for developing, estimates of consumer demand for health information.

Bioequivalency and dose proportionality of three tableted promethazine products.

Data from a five-way crossover study in human subjects using four talented promethazine products and a promethazine solution are presented. All products were administered as a single oral dose. The five objectives of the study were to investigate bioequivalency, to estimate dose proportionality at two dose levels, to establish validity of a reference production solution for future bioequivalency studies, to estimate intersubject variation, and to compare bioavailability/tablet dissolution data. Blood samples were collected at given intervals over a 24-hour period and analysed for promethazine using an HPLC technique. Pharmacokinetic parameters were calculated using standard procedures and a two-way analysis of variance (ANOVAR) was used to assess whether the differences were statistically significant. The AUC0----infinity data from the ANOVAR analysis showed that the 50 mg innovator and generic products and the 50 mg solution were not significantly different. However, the innovator product had a significantly lower Cmax and longer tmax than the solution. The generic product did not differ significantly from the solution. Promethazine was found to exhibit linear dose proportionality in the range and product studied. Intersubject variation was high for all parameters (23 to 63 per cent) and the in vivo and in vitro data showed a positive relationship.

Rotary pursuit, a measure of human performance, and plasma concentrations of promethazine.

Promethazine in doses of 50 mg has demonstrated detrimental effects upon the performance of visual tasks. The purpose of the study was to examine the relationship between the blood concentration levels of promethazine and two human performance tasks. Fifteen paid healthy male volunteers completed a randomized five-way crossover design which included a 25 mg and 50 mg dose of the innovator dosage form, a 50 mg dose of a generic dosage form, a 50 mg solution dosage form, and a placebo. Serial blood samples were obtained in addition to performance measures of rotary pursuit and a simple force choice reaction time. Analysis of the forced choice reaction depicted a mild relationship with the blood concentration levels of promethazine. However, the measures of rotary pursuit, a more sensitive determinant of human motor performance, proved to be more related to both the promethazine blood concentration and the inherent learning which was confounded in the experiment. The degree of impaired pursuit performance and reaction time differences could be defined in terms of a linear relationship to the promethazine concentration.

Polygraph testing--a comprehensive literature review of an ethical dilemma.

The purpose of this article is to provide pharmacy educators with knowledge regarding the polygraph. These facts are valuable in training and counseling students and are prerequisite to making informed decisions as leaders in the profession. Businesses lose six-billion dollars annually to employee theft. One in four U.S. employers currently use the polygraph on employees, and pharmacists are frequently subject to the procedure. Several U.S. corporations report the lowest loss rates in the industry without resorting to the polygraph. They utilize traditional techniques of security, accounting, and personnel administration. Patterns of nonspecific autonomic responses modified by race, sociability, moral development, interpersonal climate, education, pain, and exercise level, indicate that the procedure is not valid. The procedure yields approximately 11 percent false positive and 2 percent false negative results. No licensure is required in 24 states, and 40 states allow employers to use the technique at will. NACDS and NARD support of the polygraph, while the APHA and the Retail Clerks Union oppose it.

In vitro and in vivo bioequivalence of commercial prednisone tablets.

The purpose of the study was to examine the bioequivalence of five commercially available oral prednisone products. The in vivo study utilized 18 healthy males, each of whom was administered 20 mg of prednisone as a reference solution or as a tablet in a 6-week, six-way crossover design. Blood was collected and serum was assayed, using an HPLC procedure specific for prednisone and prednisolone. Mean pharmacokinetic parameters (t 1/2, ke, Cmax, tmax, and AUC) were determined. ANOVA was performed on the prednisone and prednisolone data (F-test, p less than 0.05) as well as Duncan's multiple range analysis. Dissolution tests were also performed on each of the five products in order to test the relationship between dissolution and bioequivalence among prednisone products. The in vitro study consisted of a standard USP dissolution test which included tablets from the same lots as the tablets used in the in vivo study. The data showed no statistical difference in any of the pharmacokinetic parameters among tableted products, subjects, or dosing periods in the study. There was also no statistical difference in the dissolution study among the five commercial tablet forms.

An in vivo single- and multiple-dose study of several marketed brands of conventional and controlled-release theophylline.

In a single-dose study, 18 healthy adult males consumed each of six dosage forms of theophylline. A conventional-release tablet, a syrup, and four competing brands of controlled-release theophylline were studied. Serial serum samples were obtained and analyzed via high pressure liquid chromatography (HPLC). After achieving steady state, 15 healthy adult males consumed each of five dosage forms of theophylline in a multiple-dose study. Serial blood samples were obtained between 0 and 72 hours and subjected to analysis with HPLC. The results indicated that the controlled-release products were not bioequivalent, although they achieved longer time-to-peak values than did the immediate-release syrup and the conventional-release tablet. A single sustained-release product was uniquely different on most pharmacokinetic parameters when compared with the remaining three controlled-release products. In general, the dosage form variation exceeded the individual subject variation on the single-dose study, but the opposite was true for the multiple-dose study.

Consultant pharmacist impact on antihypertensive therapy in a geriatric long-term care facility.

Antihypertensive therapy of a group of elderly patients in a long-term care facility was compared before and after the addition of a consultant pharmacist to the health care team. Criterion variables were systolic and diastolic pressure and drug cost and use. Consultant pharmacist protocol included drug history and monthly use review and pertinent communications regarding problems. Statistical analysis employed a t test with two-tailed probability. Both systolic (128.5 to 135 mm Hg) and diastolic pressure (68.9 to 72.3 mm Hg) were increased after 1 year, the number of patients with hypotensive readings decreased, and the average antihypertensive drug cost was decreased. The cost of potassium supplements was increased, however, fewer patients had abnormal potassium levels.