Drug Treatment Patterns Research Articles

The Costs of Type 2 Diabetes Mellitus in Italy

To estimate the direct, indirect, and intangible costs associated with type 2 diabetes mellitus in Italy in 1998. To evaluate the economic impact of diabetic complications, and to investigate drug treatment patterns and associated costs in patients with type 2 diabetes. The Italian arm of an international study (COsts of Diabetes in Europe--Type 2 [CODE-2], a descriptive, cross-sectional survey) was set up to collect information retrospectively by means of questionnaires from a sample of 1263 patients. Resource use was measured in monetary terms using a set of costs and tariffs. Intangible costs were estimated using the EuroQol questionnaire. The average yearly cost for medical resources for a patient with type 2 diabetes was 2991 Euro, whereas the estimated cost for the whole population with type 2 diabetes was about 5170 million Euro. This corresponds to 6.65% of the total healthcare expenditure (public and private) in Italy. Of direct costs, 29% was spent for the treatment of diabetes and 39% for the treatment of diabetic complications; while the remaining 32% was spent for healthcare not related to diabetes. Quality of life score in patients with type 2 diabetes (EuroQoL overall average score) was 0.68. Type 2 diabetes has a high cost to society. The major cost component is due to the care of diabetic complications, not to the treatment of the illness itself; in particular, drug costs represent a relatively small proportion of such treatment cost.

Gender differences in secondary prevention of coronary heart disease: reasons to worry or not?

Scand J Prim Health Care 2003;21:37-42. ISSN 0281-3432 Objective - To analyse potential gender differences in cardiovascular risk factors and treatment patterns, reflecting clinical practice in secondary prevention. Design - Observational national study during 3 years of patients eligible for secondary prevention of coronary heart disease (CHD). Setting - Fifty-two healthcare districts in Sweden, involving primary health care and hospitals in collaboration, participating in a national quality assurance programme for the prevention of CHD. Subjects - A national sample of male and female patients surviving acute myocardial infarction, or following CABG/PTCA interventions for CHD, controlled at 3-6 months (n=9135) and 12 months (n=4802) of follow-up. The proportion of female patients (25%) did not differ between visits. Main outcome measures - Self-reported data on lifestyle, drug treatment and cardiovascular risk factor levels after consultation in general practice or at hospital policlinics. Results - No major gender differences were recorded in risk factor levels or in cardiovascular drug treatment patterns at 12 months of follow-up. Female patients participated in educational programmes to improve lifestyle to a higher degree than males (52.0 vs 45.1%), but after 1 year were more often (p<0.001) self-reported smokers (11.7 vs 8.4%). Female patients showed higher levels of blood pressure, total cholesterol and HDL cholesterol, but not LDL cholesterol compared to male patients. Conclusions - In general, a gender-equal level of lipid control and access to medical drug treatment has been established for patients in secondary prevention from a national sample in Sweden, followed for 1 year after CHD manifestations and related interventions.

Irritable bowel syndrome: patterns of ambulatory health care and resource use in the United States, 1993-1997.

In the mid-1980s irritable bowel syndrome was estimated to result in 2.5 million office-based physician visits per year in the United States. This study investigates more recent patterns of ambulatory care in the United States using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey for the years 1993-1997. We estimate that there are 11.3 ambulatory physician visits per 1000 US population per year with a diagnosis of irritable bowel syndrome: 92% (2.7 million visits per year) are to office-based physicians, 7% to outpatient departments and 1% to emergency departments. Women account for 74% of visits. Drugs, most commonly gastrointestinal agents and anxiolytics, are prescribed at more than three quarters of all visits; prescribing of multiple drugs is common. Office-based physician visit rates and patterns of drug treatment have not changed markedly since the 1980s. Visit rates increase more steeply with age than previously reported.

PMH33: OLANZAPINE VERSUS RISPERIDONE IN THE TREATMENT OF SCHIZOPHRENIA: A COMPARISON OF COSTS AMONG TEXAS MEDICAID PATIENTS

plus non-schizophrenia) healthcare costs among Texas Medicaid recipients who had been diagnosed with a schizophrenic disorder and had been initiated on olanzapine or risperidone. Methods: Cost data for services and prescription use were retrieved for 2885 patients with schizophrenia who were initiated on olanzapine or risperidone between 1 January 1997 and 31 August 1998. Each patient was followed for 1 year before and 1 year after initiation of therapy. Multivariate analysis was used to control for a wide range of factors (drug choice, patient demographics, pre-utilisation costs, region, health conditions, and treatment patterns) that may influence schizophrenia-related costs and total healthcare costs. Estimation was conducted via a two-stage instrumental variables model. Results: The mean unadjusted total schizophrenia-related cost per patient per year during the observation period was $US4892, and the total unadjusted healthcare cost per patient was $US7101. Results revealed significant regional variation in schizophrenia-related and total healthcare costs. Significantly higher total healthcare costs were found for patients with other (nonpsychiatric) diagnoses, such as HIV and diabetes mellitus. Although, on average, patients taking olanzapine stayed on therapy longer than those taking risperidone (248.2 days vs 211.1 days; p < 0.0001), multivariate analysis revealed no significant difference in schizophrenia-related costs between patients who received olanzapine and risperidone ($US123 lower with olanzapine; p = 0.6439). However, patients who received olanzapine compared with risperidone had significantly lower total medical costs ($US693 lower with olanzapine; p = 0.0311). Conclusion: This naturalistic study used data from a Texas Medicaid population to examine the schizophrenia-related costs and total healthcare costs for patients who received olanzapine versus risperidone. Multivariate analysis revealed no significant differences in schizophrenia-related costs for patients receiving olan

Costs of asthma treatment in Estonia.

The aim of this study was to describe the distribution of the direct costs of asthma in Estonia by the type of treatment received and to differentiate the costs by age of patients. Data were obtained from the databases of national health insurance offices. Persons who had been in a hospital or visited a doctor because of asthma and who also purchased anti-asthmatic drugs during 1997 were identified. The bills of all direct costs of health insurance for each asthma patient could thus be summarised. The data on all purchases of drugs were used to follow the patterns of drug treatment of asthma. The mean annual treatment costs of one asthma patient were 118 EUR. The costs of hospital care accounted for 27%, costs of ambulatory care for 20% and costs of pharmacotherapy for 53% of all treatment costs. Beta-agonists and corticosteroids for inhalation accounted for more than 80% of prescriptions and 90% of pharmacotherapy costs in patients under 45 years. The users of oral corticosteroids had twice as high per capita annual asthma treatment costs as compared to non-users. The frequency of out-patient visits, hospital admissions, number of prescriptions, total costs and costs of pharmaceuticals increased in parallel with age. The total estimated direct costs of asthma diagnosis and treatment during 1997, as extrapolated from the study population, were 2.1 million EUR, and accounted for 1.4% of direct health care costs in Estonia.

Analysis of Asthma-Related Costs and Patterns of Resource Utilization in a Managed-Care Population

Objectives: To identify the asthma prevalence rate, the total healthcare and asthma-related treatment costs, and the medical and pharmacy costs associated with different asthma medication usage patterns in a managed-care organisation (MCO). Study design and participants: The medical and pharmacy claims databases from a 400 000 member MCO were used. The medical claims database was searched from 1994 to 1996 for patients having at least one asthma medical claim in either the first or second diagnosis field of the medical claims, and the total healthcare and asthma-related costs were determined. A subpopulation with a more restrictive asthma definition was identified and their costs were also determined. In addition, the patterns of drug treatment were identified. Study perspective: MCO perspective. Results: The mean total healthcare cost of caring for patients with asthma was significant and approximately twice the mean cost of all patients enrolled in the MCO. Using a broad definition of asthma, the mean (± standard deviation) annual total per patient healthcare cost was $US2511 ± 7314 and the annual asthma-related cost was $US679 ± 2247 (1996 values). Using a more restrictive definition of asthma, the mean annual total per patient healthcare cost was $US2653 ± 5268 and the asthma-related cost was $1026 ± 2447. There appeared to be a low overall use of asthma medications, especially anti-inflammatory formulations; <3% of patients with asthma were high users of anti-inflammatory inhalers. Conclusions: Patients with asthma are costly to managed-care organizations. Asthma-related costs constitute a minority (<30%) of the costs of caring for these patients, and under utilization of anti-inflammatory products by patients is widespread. Further research is needed to assess the cost impact of different asthma treatment patterns.

Health resource utilization and drug treatment pattern in a cohort of patients with a first episode of gastroesophageal reflux disease.

To describe the demographics, comorbidity, and health care resource utilization, as well as treatment patterns among gastroesophageal reflux disease (GORD) patients. We identified a population-based cohort of newly diagnosed GORD patients receiving cimetidine, ranitidine or omeprazole. Our final study population consisted of 1193 patients, who were followed up for 1 year. Mild symptoms were reported in 44% of cases, moderate in 52%, and 4% had a severe episode. Moderate and severe cases were more likely to undergo endoscopy and to be hospitalized for GORD than mild cases. They also had a higher probability of receiving long-term continuous treatment and to start initial treatment with omeprazole rather than with cimetidine or ranitidine. Initial treatment failure was greater among severe cases and in patients started on H(2)-blockers. This study has shown that severity of initial GORD episode is significantly associated with an increased use of health resources, and is the major determinant of initial treatment failure. Patients started on H(2)-blockers also had a greater risk of initial treatment failure compared to patients started on omeprazole.

Morphine-induced long-term sensitization to the locomotor effects of morphine and amphetamine depends on the temporal pattern of the pretreatment regimen.

The development of behavioural sensitization is thought to depend on the dose and temporal pattern of drug treatment. Previous studies have shown that two distinct morphine pretreatment regimens cause different long-term neuroadaptations in rat striatum. Therefore, in the present study the ability of these pretreatment regimens to induce long-term behavioural sensitization was investigated. One pretreatment regimen, termed "chronic", consisted of three daily injections, for 5 days, with escalating doses (10-50 mg/kg) of morphine, and the other, termed "intermittent", of 14 daily injections with morphine (10 mg/kg). Both intermittent and chronic morphine pretreatment caused sensitization to the locomotor effects of morphine, 3 weeks post-treatment, although the former induced a far greater level of sensitization. Moreover, 3 weeks post-treatment, intermittent, but not chronic, morphine pretreatment induced cross-sensitization to the locomotor stimulant effects of amphetamine. Behavioural sensitization following intermittent morphine pretreatment was clear-cut both 1 day and 3 weeks post-treatment, while after 9 weeks, the locomotor effects of morphine were still slightly augmented. It is concluded that intermittent morphine pretreatment is far more effective in inducing long-term behavioural sensitization than chronic morphine pretreatment.

Current drug treatment and treatment patterns with antihypertensive drugs.

The 4 major classes of antihypertensive drugs are diuretics, beta-blockers, ACE inhibitors and calcium antagonists. The diuretics have recently regained prominence, largely due to the results of recent controlled trials. These trials in elderly patients demonstrated that low-dose diuretics were effective not only in preventing stroke but also in greatly reducing coronary-related events. Diuretics also decrease left ventricular mass more than the other major drug classes. In addition, they are the most effective drugs for use in combination therapy. By contrast, the safety of calcium antagonists has recently been questioned because of report of increased coronary morbidity and mortality. However, these adverse events may be restricted to the short-acting preparations, especially nifedipine, which causes cardiac stimulation. ACE inhibitors, like beta-blockers, are not only effective in reducing blood pressure, particularly when combined with a diuretic, but also improve angina and decrease postinfarction mortality. They also benefit congestive heart failure, stabilise or improve renal function in hypertensive and diabetic nephropathy and reduce albuminuria. Beta-Blockers are especially effective in reducing sudden cardiac death in patients with coronary heart disease, particularly in postinfarction patients. Final proof of the relative effectiveness of these drugs in preventing morbidity and mortality must await the outcome of large comparative trials currently under way. A recent national survey in the US found that more than 75% of hypertensive patients did not have their hypertension completely controlled. Possible reasons for this disturbing statistic are discussed along with suggestions for improvement.

The role of medicine in the decline of hypertension-related mortality.

Mortality trends are often cited to justify public health priorities and to legitimate professional activities. For example, the decline of cardiovascular disease mortality in recent decades has been cited frequently as affirmation of the proper conduct and direction of medical and public health research. In this paper, the hypothesis that medical intervention is the major cause of hypertension-related mortality declines is reviewed. Evidence relevant to the "medical hypothesis," including mortality data and patterns of antihypertensive drug development and treatment, is presented. While it is clear that factors other than medical intervention must have played the major role in hypertension-related mortality trends for most of the period of the decline, much scientific literature increasingly promotes the view that medical intervention is the crucial factor in mortality trends. The role of the medical hypothesis in supporting status quo political and economic interests is discussed, and alternative explanations for mortality trends are considered.

Extracorporeal therapy in the treatment of intoxication.

THE GREEKS did it with hemlock, as immortalized by Socrates. The ancient physician, Galen, devoted himself to the perfection of Theriac, the universal antidote, composed of more than seventy ingredients, including viper's flesh. Poisoning is as old as the human condition; only patterns of drug use and treatment of poisoning have changed with time. While twenty years ago aspirin and barbiturates were leading causes of serious intoxication, today antidepressants, tranquilizers, and acetaminophen have taken the lead. Narcotics are an age-old source of drug intoxication and remain a major problem today. The majority of drug poisoning documentations are made through emergency room (ER) visits. The statistics available for 1981 from the Drug Abuse Warning Network (DAWN) of the National Institute on Drug Abuse l reveal that 1 out of every 166 ER visits was due to drug intoxication. Table 1 lists the ten drugs (or drug groups) most frequently mentioned by ERs in the DAWN survey. The statistics for each drug include the frequency with which it was mentioned by ERs, expressed as a percentage of total ER visits; admissions to the hospital as a percentage of ER mentions of the drug; and medical examiner mentions of the drug as a percentage of total deaths. Of note is the frequency with which drugs were taken in combination with ethanol or other drugs-46 % of ER visits and 63 % of deaths involved multiple drugs. For the benzodiazepines, in particular, over 70% of the ER mentions included another drug (ethanol half the time) and over 90 % of medical examiners mentions included at least one other drug. In fact, death rarely occurs from the ingestion (versus intravenous use) of benzodiazepines alone. Approximately 40% of drug-related cases required admission to the hospital, but less than 2.3% resulted in death (if narcotics and patients dead-on-arrival are excluded, the figure is 1.1 %). These impressive statistics on survival are relatively new. The mortality rate from drug overdose was over 20% as recently as 25 to 30 years ago, when CNS stimulation was the crux of therapy. Drugs such as pentylenetetrazol, picrotoxin, and amphetamines were considered essential and were not readily abandoned. 2.3 Even with reported increased incidences of seizures, cardiac arrhythmias, and vomiting, it took many years to recognize that mortality statistics were, in fact, worse with this aggressive intervention. 4.5 The first major step toward improvement of outcome resulted from lessons learned in the treatment of shock on the battlefields of World War II and applied by Kirkegaard6 to show the importance of circulatory collapse in intoxication. In addition, in 1951, Nilsson7 established the importance of a clear and patent airway and prevention of hypoxia. The final leap in patient care came in 1961 when Clemmesen and Nilsson8 demonstrated systematically from 12 years experience in Copenhagen averaging more than 1,500 cases of poisoning per year, that intensive supportive therapy, without massive gastric lavage or analeptic agents, resulted in mortality rates of 1.5 %. Acceptance of their Scandinavian Method, as it came to be known, and abandonment of analeptic therapy has led to the excellent mortality statistics seen today. It is toward the small group of patients who fail to respond to intensive supportive care that treatment innovations, especially extracorporeal therapy, have been directed. The rationale for extracorporeal treatment is straightforward: since poisons achieve their toxic effect on target organs via the blood stream, their elimination from the blood should result in amelioration of the patient's condition. Forced diuresis was used to accelerate elimination, but with the advent of technology for hemodialysis, direct access to and removal of poisons from the circulation became a possibility. The development of hemoperfusion permitted even more effective removal of substances from the blood. Although the pur-

The drug history of psychiatric admissions.

Many patients admitted to psychiatric hospitals give a history of recent drug treatment, and this may be important in the assessment of their clinical state. The aim of the present study was to survey the pattern of drug treatment in psychiatric patients at the time of admission, and to compare various accounts of this treatment.