Direct Drug Costs Research Articles

Cost considerations in the use of anaesthetic drugs

Measuring the direct drug costs of an anaesthetic is relatively easy, but assessing increased expenditure in relation to clinical benefits and indirect costs is not. This review examines a number of papers that have attempted just such a task and tries to illustrate some of the difficulties inherent in this important area of cost-effective analyses.

Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact

Background The use of parenteral positive inotropic agents still remains a major component of therapy for patients with advanced decompensated congestive heart failure (CHF). However, no consensus guidelines have been developed for the appropriate selection of a first-line inotropic therapy. We sought to compare the clinical outcome and economic cost of dobutamine-based and milrinone-based therapy in patients with acute exacerbation of CHF. Methods and Results We retrospectively analyzed the outcome of 329 patients admitted to the heart failure unit with acute exacerbation of CHF. More patients were treated with dobutamine-based therapy (269/329, 81.7%) than with milrinone-based therapy (60/329, 18.3%). Both groups had similar baseline characteristics and similar hemodynamic profiles at baseline, with the exception of higher mean pulmonary arterial pressure in the milrinone group (47 mm Hg vs 42 mm Hg, P < .001). One hundred nine patients (40%) of the dobutamine group required parenteral nitroprusside for hemodynamic optimization compared with 11 patients (18%) in the milrinone group (P < .001). The use of parenteral nitroglycerin and dopamine was similar in both groups. There was no significant difference in the in-hospital mortality rate (dobutamine 7.8% vs milrinone 10%) or clinical outcome between the 2 groups. However, the average direct drug cost per patient was significantly reduced in the dobutamine group compared with the milrinone group ($45 ± $10 vs $1855 ± $350, P < .0001). Conclusion Dobutamine-based therapy is an attractive approach for the treatment of decompensated advanced heart failure, achieving comparable clinical efficacy to milrinone with a significantly reduced economic cost. (Am Heart J 2001;142:998-1002.)

PDB5: A COST-MINIMIZATION STUDY TO DETERMINE THE IMPACT OF ADDING GLUCOVANCE TO A COUNTY HOSPITAL FORMULARY

OBJECTIVE: This study is conducted to determine the economic impact of the addition of a new diabetic agent, Glucovance (metformin/glyburide) to a county hospital system with over 21,000 diabetic patients. METHODS: A cost minimization analysis between Glucovance and metformin plus any of the sulfonylureas is conducted. Initially, a database of all diabetic patients in the county hospital system is created to determine total number of patients who are being treated with metformin alone and in combination with other sulfonylureas, glipizide XL, generic glipizide, glyburide, and glimepiride. Next, the cost difference between treating with Glucovance alone or as a dual therapy with both metformin 500mg plus the most common dose of each sulfonylurea is calculated to determine the incremental cost savings over a year's time of therapy. Only the direct costs of the drugs involved are utilized in this study. RESULTS: The results indicate that if all of the 6,622 patients who are on dual therapy with both metformin 500mg and a usual maintenance dose of a sulfonylurea drug are switched to the new combination product, the county system can save over half a million dollars ($555,566.00) in a year, in direct drug costs alone. CONCLUSION: These results illustrate that there is an economic incentive to add the new combination product to the formulary. However, future cost-effectiveness studies are needed to determine the impact of this decision both in terms of clinical and economic outcomes.

Impact of a pharmacist on drug costs in a coronary care unit.

The impact of clinical pharmacy services on direct drug costs in a coronary care unit (CCU) was studied. An observational, nonrandomized study was conducted on all patients admitted to the CCU to evaluate the impact of clinical pharmacy services on direct drug costs. Clinical pharmacy services were introduced into the CCU in July 1998. Patient characteristics, mean drug costs per admission, mean drug category costs per admission, and total hospital costs per admission were determined for October 1997 to June 1998 (nonintervention period), July 1998 to March 1999 (intervention period 1), and April 1999 to December 1999 (intervention period 2). The Clini-Trend program was used to estimate the total reduction in drug costs associated with documented pharmacist interventions from January to December 1999. Mean patient age, sex, admitting diagnosis-related group, Medicare case-mix index, ventilator days, length of stay, and number of deaths did not differ significantly among the three study periods. Mean +/- S.D. drug costs per admission for the nonintervention period were $374.05 +/- $75.51. With the introduction of clinical pharmacy services, mean +/- S.D. drug costs per admission were $381.94 +/- $66.16 (p > 0.1 for intervention period 1 compared with the nonintervention period) and $233.74 +/- $84.16 (p = 0.002 for intervention period 2 compared with the nonintervention period). From January to December 1999, 4151 pharmacist interventions were documented. The estimated reduction in drug costs associated with the interventions totaled $372,384. A pharmacist's clinical services in the CCU allowed for significant estimated reductions in total drug costs.

Depression in Managed Care: Costs of Selective Serotonin Reuptake Inhibitors

OBJECTIVE: To review data on the comparative costs of antidepressants. DESIGN: Review of data from articles identified in a Medline search, meeting presentations, and independent market research that are relevant to the costs associated with treating depression. Studies were included if they compared depression treatment costs with tricyclic antidepressants to those with one of the leading selective serotonin reuptake inhibitors (SSRIs) or if they compared treatment costs among the leading SSRIs. Data were extracted on drug acquisition costs, concomitant medications, dose titration, multitablet/multi-capsule therapy, duration of therapy, and overall treatment costs. RESULTS: SSRIs may be more costeffective than tricyclic antidepressants because they are associated with lower health care utilization. Assessment of economic outcomes with SSRI therapy can be based on identified cost drivers, including dose titration and the need for multi-tablet therapy. Among the SSRIs, the uses of nonpharmaceutical health care services are generally equivalent, and differences in direct drug costs may affect overall treatment costs. CONCLUSIONS: Cost for depression treatment may be reduced by using an SSRI that is associated with a favorable profile in areas identified to influence overall treatment cost, such as dose titration, need for multi-tablet and/or multi-capsule therapy, and concomitant medications.

A rapid and systematic review of the clinical effectiveness and cost-effectiveness of gemcitabine for the treatment of pancreatic cancer.

A rapid and systematic review of the clinical effectiveness and cost-effectiveness of gemcitabine for the treatment of pancreatic cancer.

Second Line Pharmacological Management of Paroxysmal and Persistent Atrial Fibrillation in France: A Cost Analysis

Objectives Despite optimal pharmacological treatment a large proportion of patients with atrial fibrillation (Afib) are not arrhythmia-free, and remain at risk for complications such as stroke and cardiac morbidity. If first-line treatment fails, most patients receive second-line pharmacological treatment. The emergence of new technologies aimed at restoring and maintaining sinus rhythm, such as catheter ablation techniques, has increased the interest in the economic aspects of second-line pharmacological treatment. The objective was therefore to calculate the 5-year direct medical costs of second-line pharmacological management of paroxysmal and persistent Afib in France. Methods The analysis was based on clinical and economic literature and the input of cardiologists-electrophysiologists. The analysis included probabilities of stroke, sudden cardiac death, other cardiac and noncardiac death, direct medical costs of drugs, follow-up and complications from the healthcare payer's perspective. Included treatment strategies were (1) rhythm control with class Ic and III antiarrhythmics and (2) rate control, consisting of digoxin combined with a beta-blocker or calcium antagonist. Both strategies included aspirin or anticoagulation therapy. Results The average total 5-year cost of Afib was 16,539 Euro (FF 108,486) per patient. The result was stable to sensitivity analysis on incidence of stroke and type of stroke prevention. The main cost drivers were follow-up visits and hospitalizations and the cost of congestive heart failure. Both items being subject to some variation, they were submitted to sensitivity analysis showing minimal 5-year costs still over 14,483 Euro (FF 95,000). Conclusion Afib management places high demands on medical resources mainly through its complications and comorbidity.

Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care.

To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing. Prospective cost-benefit analysis. Medical and surgical intensive care units (ICU) of a 350-bed tertiary care university hospital. Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics, sedatives, and/or neuromuscular junction blockers (NMJBs). There were 72 patients in the baseline and 84 patients in the follow-up groups. Prospective tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines. Several months after the introduction of guidelines, a second group of eligible follow-up patients was tracked. The use and effectiveness of analgesics, sedatives, and NMJBs, as well as cost and outcomes, were followed in both groups. Data were subsequently reviewed and analyzed. We recorded data by means of Paradox and Excel databases and included demographics, costs, outcomes (including adverse drug reactions, functional status, ventilator time in hours, lengths of stay), and mortality rates. Data were subsequently analyzed via the Winks statistical data analysis program. Both groups were similar with regard to demographics. There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality. Direct drug costs, ventilator time, and lengths of stay were reduced in the follow-up group. In addition, the use of NMJBs was reduced from 30% in the baseline group to 5% in the follow-up group. Rational use guidelines resulted in safe, cost-effective improvements in the provision of continuous analgesia, sedation, and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies.

Cost-effectiveness of salmeterol/fluticasone propionate combination product 50/250 μ g twice daily and budesonide 800 μ g twice daily in the treatment of adults and adolescents with asthma

Despite a good understanding of the disease and its treatments, asthma continues to place a large economic burden on healthcare systems. As such, it is important to consider the economic impact of alternative therapeutic options for the treatment of this condition to ensure that scarce resources are used in the most efficient manner possible. Thus, the aim of asthma management from an economic perspective is to reduce the burden of this disease through maximizing health gain with available resources.A prospective economic analysis was conducted as part of a multicentre, randomized, double-blind, comparative trial of salmeterol/fluticasone propionate combination product (SFC) 50/250 μ g twice dailyvs. budesonide (800 μ g twice daily) in adults and adolescents with asthma who were symptomatic despite treatment with inhaled corticosteroids at doses of 800–1200 μ g day−1. Treatment effectiveness was measured in terms of successfully-treated weeks, defined as a ≥5% improvement in morning peak expiratory flow, episode-free days (a day without the need for rescue medication, no nocturnal awakening or adverse events) and symptom-free days. Cost-effectiveness analyses were performed using direct healthcare and drug costs, from the perspective of the Swedish healthcare system (1998 prices), with appropriate sensitivity analyses to test the robustness of the findings.Overall, SFC produced significantly higher (P<0·001) proportions of successfully-treated weeks, episode-free days and symptom-free days. Direct asthma management costs were similar between the two groups [SEK19·6 ($US2·4) for SFCvs. SEK18·5 ($US2·2) for budesonide]. The cost per successfully-treated week was lower for SFC than for budesonide [SEK204 ($US24·8) vs. SEK300 ($US36·4) per week], as were the costs per episode-free day [SEK51·1 ($US6·2) vs. SEK75·1 ($US9·1) per day] and symptom-free day [SEK42·2 ($US5·1) vs. SEK53·0 ($US6·4) per day]. Incremental cost-effectiveness ratios showed that the additional costs to achieve additional benefits with SFC were minimal. Costs per additional successfully-treated week, symptom-free day and episode-free day with SFC were SEK31·6 ($US3·9), SEK9·2 ($US1·1) and SEK7·7 ($US0·9), respectively, relative to budesonide. Sensitivity analysis showed that the results were stable over a wide range of assumptions. The results suggest that SFC is a more cost-effective treatment than budesonide in the management of moderate to severe asthma.

Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa

Despite growing international pressure to provide HIV-1 treatment to less-developed countries, potential demographic and epidemiological impacts have yet to be characterised. We modelled the future impact of antiretroviral use in South Africa from 2000 to 2005. We produced a population projection model that assumed zero antiretroviral use to estimate the future demographic impacts of the HIV-1 epidemic. We also constructed four antiretroviral-adjusted scenarios to estimate the potential effect of antiretroviral use. We modelled total drug cost, cost per life-year gained, and the proportion of per-person health-care expenditure required to finance antiretroviral treatment in each scenario. With no antiretroviral use between 2000 and 2005, there will be about 276,000 cumulative HIV-1-positive births, 2,302,000 cumulative new AIDS cases, and the life expectancy at birth will be 46.6 years by 2005. By contrast, 110,000 HIV-1-positive births could be prevented by short-course antiretroviral prophylaxis, as well as a decline of up to 1 year of life expectancy. The direct drug costs of universal coverage for this intervention would be US$54 million--less than 0.001% of the per-person health-care expenditure. In comparison, triple-combination treatment for 25% of the HIV-1-positive population could prevent a 3.1-year decline in life expectancy and more than 430,000 incident AIDS cases. The drug costs of this intervention would, however, be more than $19 billion at present prices, and would require 12.5% of the country's per-person health-care expenditure. Although there are barriers to widespread HIV-1 treatment, limited use of antiretrovirals could have an immediate and substantial impact on South Africa's AIDS epidemic.

What role for statins? A review and economic model.

What role for statins? A review and economic model.

Cost-Effectiveness Analyses of Salmeterol/Fluticasone Propionate Combination Product and Fluticasone Propionate in Patients with Asthma II: Study Methodologies

Asthma is a common chronic disease that places a large financial burden on healthcare systems and society. It is therefore important to consider the economic impact of new asthma therapies. Three economic analyses were performed using clinical data from multicentre comparative trials of a salmeterol/fluticasone propionate combination product (50/100, 50/250 and 50/500μg twice daily) with fluticasone propionate alone (100, 250 and 500μg twice daily, respectively) in patients with asthma. Successfully treated weeks, symptom-free days and episode-free days were the parameters used to assess treatment effectiveness. The analyses were conducted from the perspective of the Swedish healthcare system and considered direct healthcare and drug costs. Cost-effectiveness and incremental cost-effectiveness ratioswere determined, and extensive sensitivity analyses were performed. This paper summarises the methods used to evaluate the study objectives.

Antiepileptic drug withdrawal--a good idea?

Patients who are seizure free for 2 years or more are candidates for antiepileptic drug (AED) withdrawal. A MEDLINE search of the English language literature from 1980-1996 was performed to identify articles dealing with AED withdrawal in both adults and children. Factors examined included advantages and disadvantages of withdrawal, risks of relapse, prognostic factors of outcome, and methods of withdrawal. Advantages include psychosocial benefits, cost savings (direct drug costs, indirect monitoring costs), and avoidance of adverse effects and toxicity. The benefits must be balanced against the risks and impact of seizure relapse, which are different for each individual patient. A review of the prognostic factors that influence the risk of relapse will aid clinicians in determining appropriate candidates for AED withdrawal.

Cost-effectiveness of ceftriaxone and amikacin as single daily dose for the empirical management of febrile granulocytopenic children with cancer.

In children undergoing anticancer chemotherapy, a granulocytopenic febrile episode is a life-threatening condition. Prompt initiation of empirical broad-spectrum antibiotics is essential to limit morbidity and mortality. To evaluate the cost-effectiveness of combination antibiotics consisting of a third generation cephalosporin and an aminoglycoside, a retrospective review of all febrile granulocytopenic patients admitted to our institution was conducted. Between June 1994 and August 1996, 183 febrile episodes in granulocytopenic children with cancer were empirically treated with ceftriaxone and amikacin in a single daily dose. 96/183 (52%) patients had absolute granulocyte count lower than 100/mm3 at the onset; 68 (37%) were affected by acute leukemia or lymphoma, 3 (1%) by chronic leukemia, 94 (51%) by solid tumors, and 21 (11%) patients underwent bone marrow transplantation. Ceftriaxone plus amikacin was effective in 135/183 (74%) patients with a median time to defervescence of 3 days (range 1-11). Economic evaluation (cost minimization analysis) was limited to the cost savings for nonreusable materials, and difference in direct drug costs in comparison with another combination regimen such as ceftazidime and amikacin. This analysis showed that compared to a 3 times daily regimen, administration of single daily doses of ceftriaxone would result in a net cost saving of US$ 11 (17,500 Italian liras) and US$ 65.6 (105,000 Italian liras) for a 1-day and a 6-day treatment period, respectively, for the treatment of a child of 30 kg body weight. Moreover, once daily therapy has the potential to lead to savings in the time of the nursing staff and may well contribute to an improved quality of life for febrile granulocytopenic children. For these reasons, in our department, ceftriaxone plus amikacin still remain the standard regimen for the empirical treatment of febrile granulocytopenic children with cancer.

Selective serotonin reuptake inhibitors. Assessment for formulary inclusion.

Depression is a common and significant health problem associated with impairment in a patient's ability to function in their role (e.g. student, worker, home-maker), and may have a fatal outcome in the case of suicide. Recently there has been progress in developing new antidepressant medications, such as the selective serotonin reuptake inhibitors (SSRIs). These agents, while no more effective than the tricyclic antidepressant (TCA) drugs, are generally better tolerated than traditional medications used to treat depression. Further, because of their adverse effect profiles, they are generally better tolerated, and safer in overdose, than the TCAs. In response to concerns about aggregate healthcare costs, formularies are being employed to control the direct costs of prescription drugs. When direct drug costs alone are considered, the TCAs are initially less expensive than the SSRIs. However, compared with those taking SSRIs, patients taking TCAs withdraw from treatment more frequently, have more accidents, experience more adverse effects that require treatment, and are more likely to die from an overdose (if it occurs). Furthermore, unsuccessful treatment may be due to noncompliance, which is frequently related to adverse effects. Medications have effects on indirect costs. For example, adverse effects may impair productivity and lead to accidents in the home and at work. There are increased hospital and indirect costs of drugs used in overdose. Medication non-compliance may lead to failure to recover from depression, which results in ongoing expense to the state in the form of disability benefit payments. The largest cost savings are often associated with indirect costs, such as reduced benefit payments and improved productivity and earnings when treatment is successful. Taking all these considerations together, it does not appear that TCAs, taken over time, are any less expensive than the newer antidepressant medications.

Impact of newer drugs and techniques on the quality of ambulatory anesthesia

Recent pharmacologic and technologic advances in anesthesia and surgery allow outpatients with complex medical problems to undergo a wide variety of diagnostic and surgical procedures on an ambulatory basis. Increasingly, however, anesthesia practitioners, as well as pharmacy and therapeutic committees, are demanding proof that a new, more costly drug or medical device is superior to existing products in achieving its desired effect, is associated with fewer adverse effects, enhances efficiency, and reduces health care costs. 19 The new field of pharmacoeconomics 71 has emphasized the importance of cost-effectiveness analyses that consider both direct and indirect costs of newer drugs and therapeutic modalities. 51 As new biomedical technology is introduced to facilitate the perioperative management of patients (e.g., computerized anesthesia information management systems), evidence that these systems enhance our ability to continue to provide high-quality, cost-effective health care will assume increasing importance. Limitations in health care resources necessitate a careful reevaluation of our clinical practices with respect to choice of drugs, supplies, equipment, and even discharge criteria. Ambulatory anesthesia and surgery will continue to increase because of the potential cost savings for patients undergoing elective operations on an outpatient basis. However, the challenge we face will be to continue to provide high-quality anesthesia care at a reduced cost. A careful examination of commonly accepted (but unproven) clinical practice patterns will be necessary to meet this challenge.