A review of biologic treatments for psoriasis with emphasis on infliximab.

Moderate-to-severe psoriasis is known to affect millions of people around the globe. This chronic disease substantially impacts patients by impairing their quality of life, causing psychosocial distress, and creating an ongoing financial burden. The biologics are the newest and most effective therapeutic weapon in the treatment of moderate-to-severe psoriasis and psoriatic arthritis that can significantly alter the course of the disease in a relatively short period of time. There is a need to review the recommended treatment guidelines for moderate- to-severe psoriasis and psoriatic arthritis as the perception and demands of patients are constantly changing. Real world experience with this class of drugs is expanding and more new biologics are becoming available.

Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.

CONTEXT: Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE: To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN: The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES: Thirty-day and 1-year survival. RESULTS: A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION: In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Cost of comorbid alcohol and drug problems.

The authors measured the comorbid effect of alcohol and other drug (AOD) problems on medical, surgical, and psychiatric inpatient charges and length of stay (LOS) in an urban hospital by use of retrospective study of hospital clinical computer data comparing AOD-affected patients with non-AOD-affected patients in terms of cost, diagnostic, demographic, and utilization variables (N = 14,768). Patients were men and women with and without comorbid history of AOD problems, admitted for medical, surgical, and psychiatric reasons. For 10 of the 20 most frequent Diagnosis-Related Groups (DRGs), total hospital charges and LOS were significantly lower in patients with comorbid AOD problems (P < 0.001). Overall, for the most frequent 20 DRGs, total charges and LOS remained significantly lower for the AOD group. Most physicians believed that AOD-affected patients were often less ill than non-AOD patients within the same DRG. Alcohol/drug-affected patients had robustly lower costs and LOS. Fragmentation of psychosocial costs and addiction treatment from general health care and the fee-for-service DRG system appear to financially reward acute-care hospitals to repeatedly treat secondary AOD sequelae without providing any apparent incentives for the treatment of the primary alcohol/drug condition itself.

Physician staffing ratios in staff-model HMOs: a cautionary tale.

Predictions of imminent large physician surpluses stem from two observations: rapid increases in the proportion of Americans in managed care plans, and the relatively lean physician staffing ratios reported for health maintenance organizations (HMOs). We use internal data from two large, mature staff-model HMOs to determine precise specialty-specific physician staffing ratios, to see whether these HMOs use fewer physicians than the fee-for-service sector uses. The two HMOs provided the equivalent of 180 physicians per 100,000 enrollees, which is near the national average and far above figures that typically are reported in the literature. Thus, caution regarding current workforce predictions is warranted.

Estimating the cost of using non-physician providers in primary care teams in an HMO: where would the savings begin?

The economic effects attributable to employing non-physician providers (NPPs) in primary care in a large HMO were estimated by calculating the per member per month (PMPM) cost for primary care provider compensation as a function of panel size for an MD/NPP provider team. After establishing an adjusted baseline of 1352 patients for an MD working alone, we hypothetically hired an NPP for each MD and increased the average panel size from 1400 to 2800 patients in increments of 200 while reducing the number of teams to keep total enrollment constant. For panel increases of less than 650 patients the addition of an NPP to a team represented a net economic loss in terms of professional service costs. By expanding the panel size for an MD/NPP team by more than 650 patients we were able to predict a linear increase in savings. The model projects that panels of 2400 patients would result in savings of $1.38 per member per month, approximately $1.65 million dollars per 100,000 enrollees per year.