Patterns of care for COPD by Japanese physicians.

OBJECTIVE: COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations. METHODS: A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines. RESULTS: For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians. CONCLUSION: Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.

Characterization of ischemic events and use of prescription antiplatelet and anticoagulant agents after stroke or transient ischemic attack.

Stroke patients are at risk for subsequent ischemic events; yet preventive therapy is often underused. An analysis was performed to determine the rate of secondary ischemic events and use of prescription antiplatelets or anticoagulants after ischemic stroke or transient ischemic attack (TIA). Patients age 25 years or older with a medical claim for stroke or TIA between July 1, 1998 and September 30, 1999 were identified from a managed care database. Patients sustaining a stroke or TIA within 6 months before the index event were excluded. Patients were categorized as hospitalized stroke, nonhospitalized stroke, or TIA and were followed for 24 months for a secondary stroke, TIA, or acute myocardial infarction (AMI). Use of prescription antiplatelet or anticoagulant agents was determined for each subgroup. Over 2 years, subsequent stroke occurred in 5.8% of patients, TIA occurred in 3.8%, and AMI occurred in 4.9%. Death occurred in 32.3% during follow-up. Hospitalized stroke patients were the subgroup at highest risk, with a 7.6% stroke rate and a 45.4% death rate within 2 years. Prescription antiplatelet or warfarin therapy was given in 45.7% of hospitalized stroke cases, 29.5% of nonhospitalized stroke cases, and 39.2% of TIA cases. Against the background of current treatment, patients who suffer a stroke or TIA are at high risk of death and a subsequent stroke within 2 years. These outcomes highlight the importance of effective secondary stroke prevention efforts for those suffering acute stroke, whether or not they are hospitalized.

COPD in Japan: the Nippon COPD Epidemiology study.

OBJECTIVES: Despite high smoking rates, few prevalence studies of COPD have been performed in Asia. The Nippon COPD Epidemiology (NICE) Study used spirometry to measure prevalence of airflow limitation in Japanese adults. METHODOLOGY: Clinical, spirometric, and risk factor exposure data were collected on 2343 subjects aged > or = 40 years who were demographically similar to the Japanese population. Airflow limitation was defined according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (FEV1/FVC < 70%). RESULTS: Prevalence of airflow limitation was 10.9%. Based upon GOLD severity criteria, 56% of these cases were found to be mild, 38% moderate, 5% severe, and 1% very severe. Airflow limitation was significantly more prevalent in males than females (16.4% vs. 5.0%; P < 0.001), in male ever-smokers than female ever-smokers (17.1% vs. 7.5%; P < 0.001), and in older subjects (3.5% in 40-49 years olds vs. 24.4% in those > 70 years; P < 0.001). Of note, airflow limitation was also found in 5.8% of non-smokers and 4.6% of those younger than age 60 years. Only 9.4% of cases with airflow limitation reported a previous diagnosis of COPD. CONCLUSIONS: Prevalence of airflow limitation in Japan is higher than previously reported, suggesting a high degree of under-recognition of COPD. The high prevalence of smoking coupled with an aging population threatens to further increase the burden of COPD, highlighting the need for enhanced screening efforts and interventions of prevention and treatment.

Cost impact of COPD in Japan: opportunities and challenges?

OBJECTIVE: The Global Initiative for Obstructive Lung Disease highlights the importance of COPD from public health, health policy and clinical perspectives. In countries such as the USA, the economic impact of COPD exceeds that of many chronic conditions. There is a paucity of data on the economic burden of COPD in Japan. METHODOLOGY: Based upon publicly available information, a prevalence-based approach was used to construct a deterministic model to estimate the total direct and indirect costs of care for COPD in Japan. Data sources included a spirometry-based epidemiological study, the peer-reviewed literature, and governmental and industrial surveys. The most current data that addressed direct and indirect costs of care were utilized. RESULTS: In Japan, the estimated total cost of COPD is 805.5 billion yen (US 6.8 billion dollars) per year; 645.1 billion yen (US 5.5 billion dollars) in direct costs and 160.4 billion yen (US 1.4 billion dollars) in indirect costs. In direct costs, inpatient care accounted for 244.1 billion yen (US 2.1 billion dollars), outpatient care 299.3 billion yen (US 2.5 billion dollars), and home oxygen therapy 101.7 billion yen (US 0.9 billion dollars). The average annual total cost per patient for moderate/severe COPD is estimated to be 435,876 yen (US 3694 dollars); 349,080 yen (US 2958 dollars) per COPD patient in direct costs and 86,797 yen (US 795 dollars) in indirect costs. CONCLUSION: COPD imposes a high economic burden on the Japanese healthcare system. Health policy makers should direct urgent attention to increasing prevention, early diagnosis, and appropriate treatment of COPD.

Estimating angina prevalence in a managed care population.

Estimations of angina prevalence were calculated using managed care administrative data and applying 3 angina-related definitions. The definitions comprised angina pectoris diagnosis codes, diagnosis and procedure codes signifying the broader condition of coronary artery disease (CAD), including angina pectoris, and diagnosis codes for the symptom of chest pain. Prevalence rates were calculated in 2000, 2001, and the combined period of 2000 and 2001 for each definition based on the number of members with at least 1 day of eligibility in each period. Results were compared with published estimates and projected to the US population. The prevalence rates per 1000 people for angina pectoris in 2000, 2001, and 2000--2001 were 12.3, 14.0, and 17.5, respectively. The prevalence rate is higher in the combined 2-year period primarily because there is little duplication in patients with angina who appear in both years, but there is significant overlap in the overall (denominator) population eligible in both years. For CAD the rates were 52.2, 59.9, and 65.4, respectively, and for chest pain they were 63.4, 75.8, and 93.4, respectively. Rates were higher in men versus women and in each successive age group. These gender and age results were observed in the projections to the US population. By comparison, the American Heart Association (AHA) estimates angina pectoris prevalence to be 35 per 1000 in 2001. The lower managed care rate for angina pectoris may reflect differences in data capture (ie, self-reported data for AHA vs claims submitted for reimbursement for managed care). AHA estimates are higher for women versus men while the managed care estimates show the opposite trend. Prevalence of angina in the United States is substantial. With the aging of the US population, numbers of patients with angina presenting to the healthcare system can be expected to increase, further adding to the cost burdens facing managed care.

Development and validation of a model to estimate stroke incidence in a population.

Stroke is a common condition with a substantial impact on health care. Using published epidemiological data, a mathematical model was created to predict annual stroke incidence in populations over 45 years old, utilizing age, gender, ethnicity, and stroke risk factor prevalence (hypertension, atrial fibrillation, diabetes, smoking, and ischemic heart disease). The purpose of this study is to assess the models ability to reliably estimate the annual number of first strokes. The model was validated against two cohorts: the Northern Manhattan Stroke Study (NM), performed in 1995 and 1996, and the Copenhagen City Heart Study (CCHS), undertaken in 1980-84, 1984-88, and 1988-93. Both cohorts provided the actual number of first strokes for respective years and risk factor prevalence. The Mantel-Haenszel test compared actual to predicted incidence rates. The two cohorts differed in risk factor prevalences, size, and demographics. For all cohort groups/years, the predicted number of annual first strokes was not statistically different from actual first stroke incidence (P > .05). In NM, the actual number of first strokes compared to predicted was 7 versus 13 (P = .18) for 1995 and 9 versus 18 (P = .08) for 1996. Actual and predicted annual strokes in CCHS for the time frames 1980-83, 1984-88, and 1988-93 were 65 versus 69 (P = .73), 72 versus 87 (P = .23), and 75 versus 93 (P = .16), respectively. The model provides a tool for estimating annual first strokes within a population, with a tendency of bias toward overestimating the number of incident strokes. This evidence-based model may be utilized by health policy makers to predict stroke burden at a population level.

Outpatient cancer drug costs: changes, drivers, and the future.

BACKGROUND: To the authors' knowledge, no analysis has examined the specific components of drug spending for overall cancer care. The authors' objective was to quantify and characterize trends in outpatient drug expenditures for cancer patients. METHODS: The authors retrospectively analyzed pharmacy and outpatient professional claims data from commercial and Medicare health maintenance organization enrollees with a solid tumor diagnosis in 1995 and 1998. Charges were subdivided by type of drug (antineoplastic drugs, chemotherapy adjuncts, supportive drugs, and drugs unrelated to cancer treatment). RESULTS: In 1995, 14,663 cancer patients received outpatient drug treatment and 13,829 patients in 1998. Total charges increased from $17.9 million (mean charge of $1218 per patient) to $27.9 million (mean charge of $2003 per patient), an average annual increase of 16%. Antineoplastic therapy constituted the largest component of cancer-related drug costs (67%) and represented 76% of the increase from 1995 to 1998. Most charges were incurred in the professional setting for agents administered by injection. The primary explanation for the increases appeared to be a shift in treatment patterns toward newer, more expensive antineoplastic agents. Supportive therapy represented 17% of the increase in cancer drug costs, followed by chemotherapy adjuncts (7%). Charges for drugs unrelated to cancer therapy increased by 21% per year. CONCLUSIONS: Antineoplastic therapy administered in an office or clinic was the single most important cost driver, with newer more expensive agents replacing older, less expensive drugs. Attempts to understand and control outpatient drug cost increases for cancer patients should focus primarily on antineoplastic therapy, especially the appropriate substitution of newer agents for older, less expensive alternatives. Some non-chemotherapy cancer drugs may offer an opportunity to improve quality of life with a relatively small effect on overall cancer drug costs.