Impact of pharmacy practices on the cost of colony-stimulating factor use in pediatric stem cell transplantation: an institution-based analysis.

PURPOSE: An evaluation of colony-stimulating factor (CSF) use in pediatric stem cell transplantation (SCT) was conducted to identify potential cost-efficiencies while preserving institutional standards of patient care. METHODS: Clinical and pharmacy records of the 55 SCTs performed during fiscal year 1995 were reviewed. Material costs per vial and per microgram, exclusive of preparation or overhead costs, were used. The best costing strategy was defined as the least expensive stocking and dispensing practice to deliver the drug actually used during the study period. RESULTS: CSFs were used in 35 of 55 transplants; 68% of usage was protocol-mandated to enhance engraftment; the remainder was associated with life-threatening complications of SCT. All use was consistent with published evidence-based guidelines. Changes in stocking and dispensing practices would result in an overall annual savings of $48,162 (fiscal year 1995 dollars), a 39% decrease in cost without a change in clinical application. CONCLUSIONS: Our analysis demonstrates that stocking and dispensing practices place significant fiscal burden in the care of pediatric-aged patients and must be carefully considered. This analysis presents a model for evaluating all components of drug cost from a global perspective, highlighting a need for examination of pharmacy and manufacturing as well as clinical practices.

Balancing efficacy with cost: antiemetic control in the pediatric stem cell transplant (SCT) population.

We studied the practice patterns regarding intravenous (i.v.) ondansetron in children receiving stem cell transplants (SCT) at The Children's Hospital, Boston to identify cost efficiencies. The pharmacy provided information on material and preparation costs on 36 patients who received i.v. ondansetron during 41 SCT in 1995. We examined the effects of frequency, duration, and route of administration on costs. There were 498 days of ondansetron administration costing $49,083 (95$). Tremendous variation existed in frequency and duration with one third receiving i.v. ondansetron once daily, despite published evidence of equivalence of once a day and divided dosing. A switch to once daily i.v. dosing for all patients would have resulted in >/=28% savings. The median duration of use was 11 days (range 1-48); placing a cap for 7-10 days based on the length of SCT conditioning regimens, would produce savings of 48-60% over current use. By shifting administration route from i.v. to oral, a savings of 67% over current use, without a cap on duration, would be realized. Identifying areas for cost savings can be achieved after thorough analysis of all the component costs. We demonstrated that significant cost reductions could be realized by simple changes in prescribing practices without jeopardizing efficacy. These savings are achieved by standardizing dosing interval, route of administration and duration of treatment without altering daily dosage or access to an effective antiemetic. Bone Marrow Transplantation (2000) 25, 553-557.

Community-based long-term care for older persons with severe and persistent mental illness in an era of managed care.

The authors describe current needs and trends in the mental health care, including long-term care, of older persons with severe and persistent mental illness. The literature suggests that emerging models of managed long-term care hold promise for integrated services but do not currently address the specialized mental health needs of this patient group. The authors review issues in financing long-term mental health care, including controversies over fee-for-service and carve-out and carve-in arrangements. Without mechanisms to adequately finance services, adjust for risk, and measure outcomes, the authors conclude, managed care arrangements will be in conflict with the goal of high-quality care for older adults with severe and persistent mental illness. Proposed directions for future models of care for this group include integration of mental health and medical services, integration of specialized geropsychiatric services with developing community-based long-term care systems, blended financing under shared risk arrangements, and assurance of accountability and outcomes under managed care.

Anglers' attitudes, beliefs, and behaviors as impacted by the Michigan Fish Consumption Advisory.

This study examines the relationship between a person's knowledge that a current ego-involving behavior may include health risks and the undertaking of a subsequent behavior change to reduce this risk. Specifically, 396 licensed anglers were surveyed concerning their beliefs about the health risks of consuming sport-caught fish, their knowledge of the risk information contained in the Michigan Fish Consumption Advisory, and their personal fish consumption behavior. Sixty-five percent of the anglers surveyed reported reading part or all of the Michigan Fish Consumption Advisory; however, as a group, they perceived the risks from eating sport-caught fish as small.

Transient transfection of murine B lymphocyte blasts as a method for examining gene regulation in primary B cells.

Studies of the biochemical and genetic processes associated with activation of B lymphocytes have contributed much to the understanding of the regulation of the B cell response to antigen. Primary, non-transformed B cells from the spleen in mice and the tonsils or peripheral blood in humans have proven to be informative models for dissection of the biochemical events leading to B cell activation. In contrast, genetic studies of this process have relied on transformed cell lines grown in culture. The influence of the transformed state on the results obtained using these models may limit their physiological relevance. This report describes a method whereby non-transformed B lymphocytes in primary culture can be transfected for use in studies of gene regulation in response to antigen receptor signals. Transfection was accomplished after only a 72 h exposure to LPS. The cells obtained after LPS treatment were greater than 97% pure, and more importantly, remained responsive to antigen-receptor generated signals. Responsiveness was confirmed by demonstrating induction of mRNA for the primary response gene egr-1, as well as induction of specific transcription factor binding activity in nuclear extracts from these cells. DEAE-dextran-mediated transient transfection was utilized to introduce an egr-1 promoter/reporter construct into these cells. This analysis of promoter activity yielded results which were indistinguishable from the pattern of expression of the endogenous egr-1 gene. Potential applications for dissection of transcriptional regulatory pathways in B lymphocytes are discussed.