Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model.

BACKGROUND AND OBJECTIVE: Clinicians must choose between an increasing number of medications for the treatment of pulmonary arterial hypertension (PAH) with different routes of administration, adverse effects, costs and efficacies. We constructed a decision analysis to help inform treatment choices in PAH. METHODS: We created a Markov-type model to evaluate 1-year treatment with bosentan, treprostinil, epoprostenol, inhaled iloprost, sildenafil, sitaxentan and ambrisentan. Transition probabilities were based on observed transitions between WHO functional classes, adjusted by relative risk of improvement in a 6-minute walk test. Utilities were based on reported values for each functional class, adjusted for burden of treatment administration. Costs were estimated from Medicare and Medicaid reimbursement data. Sensitivity analyses evaluated changes in efficacy, utilities and costs. RESULTS: Treatment with sildenafil was less costly and resulted in a greater gain in quality-adjusted life-years (QALYs) compared with other treatments. Treatment with ambrisentan and bosentan resulted in the same gain in QALYs as sildenafil, but at a higher cost. Sensitivity analyses had minimal impact on these results. CONCLUSIONS: Based on this model, sildenafil is a cost-effective treatment for PAH with a low price and a net increase in QALYs. The results from this analysis are a tool to help guide clinicians in deciding which PAH medications to use; however, the final decisions should be individualized because the effectiveness of therapy, resulting utilities and acceptable costs will differ with each patient.

Impact of a dual PharmD/MBA degree on graduates' academic performance, career opportunities, and earning potential.

OBJECTIVE: To evaluate the academic experience and satisfaction of students who completed a dual PharmD/MBA degree program and the program's long-term impact on the students' career choice and earning potential. METHODS: GPAs, job placement, and starting job salaries were compared between graduates who completed the dual PharmD/MBA program and those who completed only the PharmD program. A satisfaction survey instrument was administered to 17 students who completed the dual PharmD/MBA degree program in May 2007. Data from a standardized job placement and starting salary survey instrument completed by all PharmD graduates were also obtained, as well as all students' final grade point averages (GPAs). GPAs, job placement, and starting job salaries were compared between graduates who had completed the dual PharmD/MBA program and those who had completed only the PharmD program. RESULTS: The graduating GPAs of dual-degree students were higher than those of both pharmacy (3.52 vs 3.41, p > 0.10) and business (3.82 vs. 3.68, p = 0.018) students not enrolled in the dual-degree program. Dual-degree students were slightly less likely to enter a residency (17% vs. 27%, p = 0.44) than other pharmacy graduates. Among those who elected not to pursue a residency, both mean starting salaries ($111,090 vs. $101,965) and mean total first-year compensation ($127,290 vs. $110,388) were significantly higher for dual-degree graduates compared to the PharmD graduates. CONCLUSIONS: Students enrolled in the dual-degree program did slightly better academically than students who completed only the MBA or PharmD programs and indicated a high level of satisfaction with the program. Dual-degree graduates reported increased career opportunities and were slated to earn significantly more during their first year in the workforce. These results affirm continuation of our program and make the case for support of similar programs across the nation.

Impact of clinical pharmacist intervention on diabetes related quality-of-life in an ambulatory care clinic

The purpose of this one-year observational study was to evaluate quality of life in patients at the Medical University of South Carolina Family Medicine clinic who were followed by a clinical pharmacist diabetes educator. Methods: Patients who have been seen by the clinical pharmacist for diabetes education and management services were contacted by telephone and asked to complete a previously validated Diabetes-related Quality of Life (DRQL) survey. In addition, the patient's most recent hemoglobin A1C, blood pressure, fasting lipid panel and aspirin use were obtained from the electronic medical record. Correlation and logistic regression analysis was completed in order to assess the quality of life score and clinical outcomes. Results: A total of 47 patients completed the survey (37%). The median overall score was 1 (1-very satisfied; 5-very dissatisfied). Patients who were more satisfied with their current treatment tended to have lower LDL, systolic and diastolic blood pressure (BP) values (r=0.32, 0.3, 0.33; p=0.03, 0.03, 0.02). In addition, patients taking more medications were more dissatisfied with the amount of time spent managing their disease (r=0.29, p=0.04), felt more pain associated with the treatment of their disease (r=0.32, p=0.02), and were more worried that their body looked different as a result of their diabetes (r=0.32, p=0.02). Conclusion: Patients in this clinic were highly satisfied with their quality of life. The authors found that trends exist for relationships between several important clinical parameters and quality of life (AU)

El objetivo de este estudio observacional de un año fue evaluar la calidad de vida en pacientes en la clínica de medicina familiar de la Universidad de Carolina del Sur que eran seguidos por un farmacéutico clínico educador de diabetes. Métodos: Se contactó por teléfono a los pacientes que habían sido vistos por el farmacéutico clínico para su educación en diabetes y la gestión de servicios, y se les pidió que completasen un cuestionario previamente validado del Diabetes.related Quality of Life (DRQL). Además, se obtuvieron de la historia clínica los valores más recientes de hemoglobina A1C, presión arterial, perfil lipídico en ayunas y uso de aspirina. Se realizó un análisis de correlaciones y de regresión logística para evaluar la puntuación de calidad de vida y los resultados clínicos. Resultados: Un total de 47 pacientes completaron el estudio (37%). La mediana de la puntuación global fue de 1 (1-muy satisfecho; 5-muy insatisfecho). Los pacientes más satisfechos con su tratamiento actual tendían a tener menores valores de LDL, presión arterial sistólica y diastólica (r=0.32, 0.3, 0.33; p=0.03, 0.03, 0.02). Además, los pacientes que toman más medicamentos estaban más insatisfechos con el tiempo empleado en cuidar de su enfermedad (r=0.29, p=0.04), sentían más dolor asociado al tratamiento de su enfermedad (r=0.32, p=0.02), y estaban más preocupados de que su cuerpo pareciese diferente por causa de la diabetes (r=0.32, p=0.02). Conclusión: Los pacientes de esta clínica estaban altamente satisfechos con su calidad de vida. Los autores encontraron que existen tendencias de las relaciones entre varios parámetros clínicos importantes y la calidad de vida (AU)

Student satisfaction and academic performance in a dual PharmD/MBA degree program.

OBJECTIVES: Evaluate the academic experience and satisfaction of students enrolled in the dual PharmD/MBA degree program between the South Carolina College of Pharmacy and The Citadel's School of Business Administration. Compare grade point averages of students enrolled in the dual degree program with those of traditional student colleagues. METHODS: A standardized satisfaction survey instrument was administered to 32 students currently enrolled in the dual PharmD/MBA degree program. Grade point averages (GPAs) in both pharmacy and business coursework were also collected for analysis. RESULTS: There were slightly higher percentages of both female and minority students in the dual degree program compared to the pharmacy class as a whole. Eighteen (56%) of students completed the survey, and responses were generally positive. The mean GPA of students in the dual degree program was higher than that of both pharmacy (3.37 vs 3.08, p < 0.001) and business (3.72 vs 3.64, not statistically significant) students not enrolled in the dual degree program. CONCLUSIONS: Students enrolled in the dual degree program did better academically than their counterparts and indicated an overall high level of satisfaction with the program.

Charges for hospital admissions attributable to health disparities for African-American patients, 1998-2002.

OBJECTIVE: Racial disparities exist across most major disease categories, which result in a disproportionately large number of hospital admissions for many conditions. Estimates for the financial impact of the racial admission differences for the State of South Carolina are assessed. METHODS: South Carolina hospital discharge data for 1998-2002 was used for the analysis. The database includes all-payer billing data for inpatient hospital admissions as received on the UB-92 billing file for the covered episode. Charges were inflation adjusted to 2002 constant dollars. RESULTS: For 1998-2002, there were an estimated dollar 1.6 billion in total charges for hospital admissions in South Carolina that were attributed to higher age-adjusted admission rates for African-American patients. In addition, African Americans had consistently higher hospital admission rates for disease categories that are often associated with a failure to obtain ambulatory and preventive care. CONCLUSION: This simple analysis reveals that age-adjusted hospital admission rates for African Americans in South Carolina are higher than for Caucasians, and the gap appears to be widening over time. Given the magnitude of the financial implication, interventions with even a small impact on the conditions underlying the racial disparities in hospital admissions are likely to be cost effective.

5-year evaluation of electronic medical record flag alerts for patients warranting secondary prevention of coronary heart disease.

STUDY OBJECTIVES: To assess the effect of flag alerts that were placed in electronic medical records on patients' adherence with National Cholesterol Education Program (NCEP) guidelines for secondary prevention of coronary heart disease. A secondary objective was to identify the proportion of patients who were prescribed lipid-lowering agents and assess the barriers of patients who did not reach low-density lipoprotein cholesterol (LDL) goals 5.6 years after the intervention. DESIGN: Retrospective analysis of a prospective medical record intervention. SETTING: University-based primary care clinic. PATIENTS: Eighty-nine adult patients with atherosclerotic vascular disease. INTERVENTION: For each patient identified as needing secondary prevention for coronary heart disease according to NCEP guidelines, flags were inserted into the patient's electronic medical record. MEASUREMENTS AND MAIN RESULTS: Baseline patient data were collected. After 5.6 years, we performed a retrospective analysis. At that time, 72 patients were evaluated; 17 were lost to follow-up. Fifty-four percent of patients (39 of 72 patients) had reached their LDL goal compared with 25% (16 of 64 patients for whom complete lipid panels had been obtained) at baseline (p=0.001). The proportion of patients prescribed lipid-lowering agents rose from 16% at baseline to 75% at follow-up (p=0.0001). However, 33 patients (46%) were above their LDL goal levels at follow-up. Reasons for failure to reach LDL goal were as follows: drug dosage not titrated (10 patients [30%]), adverse drug reaction (four patients [12%]), planned to adjust therapy in the future (three patients [9%]), high drug cost (two patients [6%]), drug contraindicated (two patients [6%]), and non-compliance (one patient [3%]). In 11 patients (33%), the reason for failure was not addressed in the progress notes. Thus, inadequate drug dosage titration (dosage not titrated, planned to adjust therapy, and reason not addressed [assume no action]) occurred in more than 70% of these patients. CONCLUSIONS: These findings emphasize the need for regular evaluation of patients' lipid panels followed by appropriate therapy titration to reach LDL goals. Further study of factors influencing cholesterol management and methods to improve adherence is needed.

The effect of cost construction based on either DRG or ICD-9 codes or risk group stratification on the resulting cost-effectiveness ratios.

BACKGROUND: As cost-effectiveness analyses (CEAs) are increasingly used to inform policy decisions, there is a need for more information on how different cost determination methods affect cost estimates and the degree to which the resulting cost-effectiveness ratios (CERs) may be affected. The lack of specificity of diagnosis-related groups (DRGs) could mean that they are ill-suited for costing applications in CEAs. Yet, the implications of using International Classification of Diseases-9th edition (ICD-9) codes or a form of disease-specific risk group stratification instead of DRGs has yet to be clearly documented. OBJECTIVE: To demonstrate the implications of different disease coding mechanisms on costs and the magnitude of error that could be introduced in head-to-head comparisons of resulting CERs. METHODS: We based our analyses on a previously published Markov model for HIV/AIDS therapies. We used the Healthcare Cost and Utilisation Project Nationwide Inpatient Sample (HCUP-NIS) data release 6, which contains all-payer data on hospital inpatient stays from selected states. We added costs for the mean number of hospitalisations, derived from analyses based on either DRG or ICD-9 codes or risk group stratification cost weights, to the standard outpatient and prescription drug costs to yield an estimate of total charges for each AIDS-defining illness (ADI). Finally, we estimated the Markov model three times with the appropriate ADI cost weights to obtain CERs specific to the use of either DRG or ICD-9 codes or risk group. RESULTS: Contrary to expectations, we found that the choice of coding/grouping assumptions that are disease-specific by either DRG codes, ICD-9 codes or risk group resulted in very similar CER estimates for highly active antiretroviral therapy. The large variations in the specific ADI cost weights across the three different coding approaches was especially interesting. However, because no one approach produced consistently higher estimates than the others, the Markov model's weighted cost per event and resulting CERs were remarkably close in value to one another. CONCLUSION: Although DRG codes are based on broader categories and contain less information than ICD-9 codes, in practice the choice of whether to use DRGs or ICD-9 codes may have little effect on the CEA results in heterogeneous conditions such as HIV/AIDS.