Pharmacoeconomics of anticoagulants in acute coronary syndrome and percutaneous coronary intervention.

Economic evaluation plays an important role during almost all stages of pharmaceutical design and use. This paper reviews the recent pharmacoeconomic literature on the use of anticoagulants for acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI). Both ACS and PCI are common reasons for hospitalization and contribute significantly to costs of care. ACS and PCI practice standards are still evolving. For ACS enoxaparin does appear to be more cost-effective around the globe than unfractionated heparin (UFH) when clopidrogel and glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors are not used. With the high prevalence of clopidrogel and GP IIb/IIIa use, the question may be moot. Since the cost of UFH therapy, including the cost of anticoagulant monitoring, is less expensive than enoxaparin therapy, UFH is probably the more cost-effective strategy. For PCI, as ischemic complications were reduced during the mid'90's, bleeding complications have become the most common problem and a major cost driver. Other complications that can drive costs include the occurrence of MI and revascularization procedures (repeat PCI or CABG). Results suggest that bivalirudin plus a provisional GP IIb/IIIa inhibitor is the most cost-effective strategy for patients undergoing elective PCI. There is no clear evidence regarding its use in urgent PCI. ACS and PCI practice standards are still evolving. It would be useful to embed economic studies within new clinical trials. Full economic analysis of groups at high risk for bleeding while undergoing PCI is needed.

Antidepressant prescribing to Hispanic and non-Hispanic white patients in primary care.

OBJECTIVE: To examine whether there was a difference in the prescribing of selective serotonin-reuptake inhibitors (SSRIs) and non-SSRI antidepressants to Hispanic and non-Hispanic white patients in primary care. METHODS: Twenty-seven family practice and internal medicine resident physicians and 407 of their Hispanic and non-Hispanic white patients who were fluent in English or Spanish participated in the study The medical records of all patients were reviewed and information about patient diagnoses and antidepressant prescriptions was abstracted. Logistic regression was used to examine whether Hispanic ethnicity influenced physician prescribing of SSRI and non-SSRI antidepressants while controlling for other patient characteristics and diagnoses. For patients with a diagnosis of depression, logistic regression was used to examine whether Hispanic ethnicity influenced whether patients received antidepressant treatment while controlling for other patient characteristics RESULTS: Twenty-seven percent of patients received a prescription for one or more antidepressants. Hispanic and non-Hispanic white patients were equally likely to be prescribed SSRI and non-SSRI antidepressant medications. Having a diagnosis of depression and having a diagnosis of chronic pain was significantly correlated with the prescribing of a non-SSRI antidepressant (p < 0.001, p < 0.01, respectively). Having a diagnosis of depression was significantly correlated with the prescribing of an SSRI antidepressant (p < 0.001). Hispanic and non-Hispanic white patients with a diagnosis of depression were equally likely to be prescribed antidepressant treatment. Patients with a diagnosis of depression in the general medicine clinic were significantly less likely to receive antidepressant therapy than patients in the family practice clinic. CONCLUSIONS: Hispanic ethnicity did not influence antidepressant prescribing. Future research in other settings is needed to further determine whether Hispanic ethnicity influences antidepressant prescribing.