Short-term Health Care Research Articles

Glimepiride versus pioglitazone combination therapy in subjects with type 2 diabetes inadequately controlled on metformin monotherapy: results of a randomized clinical trial

ABSTRACTObjective: To compare the effect of add-on glimepiride or pioglitazone in subjects with type 2 diabetes inadequately controlled on metformin monotherapy.Research design and methods: Multicenter, randomized, parallel-group, open-label, forced-titration study involving 203 adults with poorly controlled type 2 diabetes (A1C 7.5–10%) on metformin monotherapy. Subjects were randomized to receive glimepiride or pioglitazone, titrated to the maximum dose for 26 weeks. Subjects were evaluated for A1C changes, fasting plasma glucose (FPG), insulin, C‐peptide, and lipid levels. Safety outcomes and diabetes-related healthcare resource utilization were also evaluated.Results: Both treatment groups achieved similar and significant mean decreases from baseline to endpoint (week 26) in A1C ( p = 0.0001) and FPG ( p < 0.05). Glimepiride therapy, however, resulted in a more rapid decline in A1C levels at weeks 6, 12, and 20 vs. pioglitazone ( p < 0.05). A mean A1C ≤ 7% was reached faster in the glimepiride group (median, 80–90 days vs. 140–150 days [p = 0.024]). Total and LDL cholesterol were significantly higher with pioglitazone treatment than with glimepiride at endpoint ( p < 0.05). Glimepiride treatment was associated with an increased risk of hypoglycemia and pioglitazone with higher rate of peripheral edema. Healthcare resource utilization was similar between groups, but total healthcare costs were significantly lower for glimepiride versus pioglitazone over the course of the study, driven largely by drug costs. The use of fasting C‐peptide concentration ≥ 0.27 nmol/L in the inclusion criteria was a potential limitation as it may have included those patients with an improved probability for glimepiride or pioglitazone response. In addition, a larger patient population would have provided a greater degree of data applicability.Conclusions: In patients with type 2 diabetes inadequately controlled on metformin monotherapy, add-on glimepiride or pioglitazone results in similar overall improvements in glycemic control. Compared with pioglitazone, glimepiride is associated with faster glycemic control, lower total and LDL cholesterol levels and reduced short-term healthcare costs.

Disaster Relief--What Can I Do to Help?

The recent tsunami disaster has led people throughout the world to ask: How can I help? As health care professionals, we wonder how our skills might help those in need. After a disaster, the first responding agencies have limited roles for volunteers. When recovery efforts are complete and basic infrastructure is in place, there is usually a need for long-term health care support. Well-organized, short-term health care teams can be of tremendous value to a recovering community. Most international agencies responding to disasters do not have the capability to mobilize large numbers of short-term volunteer teams. This is the role of the volunteer organizations. The value of health professional teams is directly related to how well volunteers are recruited, oriented, and equipped. Over the past 12 years, I have mobilized teams of health professionals to remote regions of Central Asia and, as a flight surgeon in the US Air Force, I participated in disaster responses. While disaster response and routine humanitarian support may be different in many ways, many of the logistical issues confronting volunteers on short-term teams are the same. It is for this reason that I am presenting these practical lessons. I hope Permanente Medical Groups, as well as other medical groups, will take steps to develop the capability of sending numerous volunteer teams to countries in need, today and for years to come. Sidebar 1. The Three-Way Partnership Defined A. Partnering Agency: Identify the most appropriate site and mission for the health care team Provide the field coordinator or identify a capable person in the field Provide the necessary clearance from local authorities Few agencies, if any, have the capability for fulfilling what is stated below under Team Leader. Partnering Agencies do not mobilize teams of professionals, especially on a large scale for a short term. B. Field Coordinator: Primary contact for the team leader Works with local authorities to tentatively plan clinic operations Provides appropriate cross-cultural orientation Organizes the pool of translators Determines housing and food sources C. Team Leader: Responsible for selection, orientation, and equipping the team Collaborates with the Field Coordinator in pretravel planning Is the on-site supervisor If possible, makes a pre-trip to the field Overall responsibility for accomplishing team mission and creating a positive experience for first-time volunteers

Short‐Term Efficacy of a Telephone Intervention by Expert Nurses After An Implantable Cardioverter Defibrillator

The ICD is a common therapy for treatment of ventricular arrhythmias and prevention of sudden cardiac death. After ICD therapy, 50% of survivors are known to have significantly elevated anxiety, depression, anger, and fear in getting back to normal physical activities. Despite these problems, few interventions to improve adjustment have been rigorously evaluated within a clinical trial format. This article reports the short-term efficacy of a structured weekly educational telephone intervention (8 weeks) delivered by expert cardiovascular nurses to recipients of an ICD. To test these effects, a two-group (n = 84/group) randomized clinical trial design was used with measures at baseline (hospital discharge), 1 month, and 3 months after ICD therapy. The study sample were first time ICD recipients for secondary prevention of sudden cardiac arrest. Primary outcomes included (1) physical functioning (Patient Concerns Assessment [PCA], Short-Form Health Survey [SF-12], ICD shocks), (2) psychological adjustment (State-Trait Anxiety Inventory [STAI]), Centers for Epidemiologic Studies-Depression (CES-D), (3) knowledge (Sudden Cardiac Arrest [SCA] knowledge assessment), and (4) health care use (emergency room visits, outpatient visits, hospitalizations). The intervention group, as compared to the control group, significantly reduced mean PCA symptoms at 1 month (11.3-8.8 vs 9.7-9.3, respectively, P < 0.02), and reduced state anxiety (36.1-31.9 vs 33.1-33.0, respectively, P < 0.08), and enhanced knowledge (21.8-22.4 vs 21.4-21.7, respectively, P < 0.02) at 3 months. The intervention did not significantly impact short-term health care use. A structured telephone intervention delivered during the first 8 weeks after ICD therapy by expert cardiovascular nurses decreased ICD related physical symptoms and anxiety, and increased SCA knowledge over 3 months.

Willingness to pay for avoiding coronary restenosis and repeat revascularization: results from a contingent valuation study

Background: Despite technological improvements, percutaneous coronary intervention (PCI) remains limited by restenosis requiring further revascularization procedures during the ensuing year. New technologies aiming to reduce restenosis are expensive and may increase net healthcare costs. Economic evaluations of such therapies have been performed, but have been hindered by the need to assess the disutility of short-term health care events and repeat coronary revascularization as well as the lack of benchmark standards for intermediate health outcomes. The contingent valuation approach may offer particular advantages when evaluating treatments that improve short-term health outcomes. Objective: To examine patients’ willingness to pay (WTP) for treatments that may reduce the risk of restenosis and repeat revascularization after PCI. Methods: We used a contingent valuation approach to evaluate WTP among participants in two large clinical trials evaluating new PCI devices. The baseline scenario described a 30% probability of repeat revascularization following the initial procedure. Patients were asked to indicate, using a close-ended (referendum) question, their out of pocket WTP for an improved treatment that would reduce this risk. Three different prices ($ 500, $ 1000, and $ 1500) and three levels of absolute risk reduction (10, 20, and 30%) were randomly varied creating nine sub-samples of patients. Patients’ responses were analyzed using both parametric and non-parametric methods. Results: 1642 patients completed the WTP question. The WTP medians for the 10 and 20% risk reductions were $ 273 and $ 366, respectively; the median WTP for the 30% risk reduction was significantly higher at $ 1162 ( P<0.001). Higher household income (OR=1.57, P<0.001) was independently associated with a higher WTP. Conclusions: Although short-lived, avoidance of coronary restenosis may have considerable value to patients undergoing percutaneous coronary interventions. These findings may have important implications for emerging technologies such as drug-eluting stents.

A pharmacoeconomic evaluation of aggressive cholesterol lowering in Sweden

Objective: To estimate the short-term healthcare costs and incremental cost per event avoided, associated with aggressive atorvastatin treatment in patients with acute coronary syndrome in Sweden. Methods: The total expected 16-week healthcare costs per patient on atorvastatin 80 mg per day and placebo were compared using clinical outcomes data from The Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study and Swedish cost data sources. The incremental cost per event avoided was also assessed for. The clinical outcomes measured in this pharmacoeconomic analysis included: death, cardiac arrest, non-fatal myocardial infarction, fatal myocardial infarction, angina pectoris, non-fatal stroke, congestive heart failure, and surgical or percutaneous coronary revascularizations. All direct medical costs were taken into account. Results: The probability of the occurrence of an event was 40.4% per patient in the placebo cohort and 36.6% per patient in the atorvastatin cohort. The total expected cost per patient was SEK 17,887 (1950.21€ 1 1 1 EUR=9.17231 SEK. ) in the placebo group and SEK 18,465 (2013.06€) in the atorvastatin group, resulting in an incremental cost of SEK 578 (63.0137€) per patient. The cost per event avoided was SEK 15,076 (1643.64€). Sixty six percent of the cost of atorvastatin treatment was offset by the cost savings obtained through the reduction in the number of events in the atorvastatin group compared to the placebo group. Conclusions: In Sweden, the clinical benefits of aggressive short-term atorvastatin treatment administered within a few days after acute coronary syndrome is associated with a substantial hospitalization cost offset secondary to the clinical benefits of atorvastatin.

Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults

Background Better understanding the impact of changes in physical activity behavior on short-term health care charges may inform resource allocation decisions to increase population levels of physical activity. This study examines the prospective relationship of changes in physical activity status on short-term changes in health care charges for older adults. Methods A prospective cohort study was done on a stratified random sample of 2,393 adults aged 50 and older enrolled in a Minnesota health plan, predicting changes in resource use between two periods (September 1994 to August 1995 and September 1996 to August 1997) based on billed health care charges. Results After adjustment for age, gender, comorbidity, smoking status, and body mass index, all physical activity states had declining health care charges, relative to those who were consistently inactive. Subjects who increased their physical activity from 0–1 to 3+ days/week had significant declines in their mean annualized total charges (−$2,202, P < 0.01) relative to those who remained inactive. Conclusions Increased physical activity among older adults is associated with lower health care charges within 2 years, relative to charges for those who were persistently inactive. These cost savings may justify investments in effective interventions to increase physical activity in older adults.

Economic issues in the use of office spirometry for lung health assessment.

The National Lung Health Education Program (United States) has recently recommended using office spirometry to screen for subclinical lung disease in adult smokers. No published studies evaluate the economic consequences of this recommendation. This review article outlines the issues that must be considered when evaluating the costs and health benefits of office spirometry. Much of the available data on the effectiveness of screening is from studies that included smoking cessation interventions, making it difficult to determine the effects of screening alone. The sensitivity and specificity of screening spirometry are not known, but may not be important in the economic model, because even false positive test results are beneficial if they lead to smoking cessation. Costs to be considered include those of spirometry itself, of implementing and maintaining screening and smoking cessation programs, and of their consequences, ie, reduced morbidity (lower short term health care costs) and mortality (perhaps higher long term health care costs). Despite these unique challenges, data are available to perform economic analyses regarding screening spirometry. Such analyses should play a role in future clinical policy making. Even modest quit rates attributable to screening spirometry may result in highly favourable cost effectiveness ratios.

A Pharmacoeconomic Evaluation of the Myocardial Ischaemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Study in the United Kingdom

To determine the short-term healthcare costs associated with intensive lipid lowering with atorvastatin initiated within 24-96 hours of the occurrence of acute coronary syndrome (ACS) in patients in the UK. Patient-level clinical outcome data from the Myocardial Ischaemia Reduction with Aggressive Cholesterol Lowering (MIRACL) trial and standard cost data were used to compare the total expected 16-week cost per patient on atorvastatin 80 mg/day versus placebo. Clinical outcomes assessed included the following: death; cardiac arrest with resuscitation; nonfatal myocardial infarction; worsening angina pectoris with objective evidence of myocardial ischaemia requiring rehospitalisation; surgical or percutaneous coronary revascularisation; nonfatal stroke; hospitalisation for angina without objective evidence of myocardial ischaemia; and new or worsening congestive heart failure requiring rehospitalisation. All relevant direct medical costs from the perspective of the NHS were considered. The total expected cost was pound 784.05 per patient in the placebo cohort and pound 851.59 per patient in the atorvastatin cohort, resulting in an incremental cost of pound 67.54 per patient in the atorvastatin group. The cost per event avoided was pound 1762.04. A third of the cost of atorvastatin treatment was offset within 16 weeks by the cost savings resulting from the reduction in the number of events in the atorvastatin cohort compared with the placebo cohort. The clinical benefits of short-term intensive atorvastatin treatment administered after ACS is attainable through a marginal increase in 'upfront' costs.

Utilization and cost of behavioral health services: employee characteristics and workplace health promotion.

The study sought to (1) model demographic and employment-related influences on behavioral health care utilization and cost; (2) model behavioral health care utilization and cost influences on general health care cost, job performance, and earnings; and (3) assess workplace-based health promotion's impact on these factors. Behavioral health care utilization was more common in employees who were female, over age 30, with below-median earnings, or with above-median general (non-behavioral) health care costs. Among employees utilizing behavioral health care, related costs were higher for employees with below-median earnings. Employees utilizing behavioral health care had higher general health care costs and received lower performance ratings than other employees. Health promotion participants were compared with a nonparticipant random sample matched on gender, age, and pre-intervention behavioral health care utilization. Among employees without pre-intervention behavioral health care, participants and nonparticipants did not differ in post-intervention utilization. Among employees utilizing behavioral health care adjusting for pre-intervention costs, participants had higher short-term post-intervention behavioral health care costs than nonparticipants.

Drinking patterns, health care utilization, and costs among HMO primary care patients.

A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking.

Relationship Between Modifiable Health Risks and Short-term Health Care Charges

If physical inactivity, obesity, and smoking status prove to contribute significantly to increased health care charges within a short period of time, health plans and payers may wish to invest in strategies to modify these risk factors. However, few data are available to guide such resource allocation decisions. To examine the relationship of modifiable health risks to subsequent health care charges after controlling for age, race, sex, and chronic conditions. Cohort study of a stratified random sample of 5689 adults (75.5% of total sample of 7535) aged 40 years or older who were enrolled in a Minnesota health plan and completed a 60-item questionnaire. Resource use as measured by billed health care charges from July 1, 1995, to December 31, 1996, compared by health risk (physical activity, body mass index [BMI], and smoking status). The mean annual per patient charge in the total study population was $3570 (median, $600), and 15% of patients had no charges during the study period. After adjustment-for age, race, sex, and chronic disease status, physical activity (4.7% lower health care charges per active day per week), BMI (1.9% higher charges per BMI unit), current smoking status (18% higher charges), and history of tobacco use (25.8% higher charges) were prospectively related to health care charges over 18 months. Never-smokers with a BMI of 25 kg/m2 and who participated in physical activity 3 days per week had mean annual health care charges that were approximately 49% lower than physically inactive smokers with a BMI of 27.5 kg/m2. Our data suggest that adverse health risks translate into significantly higher health care charges within 18 months. Health plans or payers seeking to minimize health care charges may wish to consider strategic investments in interventions that effectively modify adverse health risks.

Accountability in Public Short-Term Adult AOD Residential Treatment

Fontainebleau Treatment Center provides short-term public residential AOD treatment and primary health care to a lower-socioeconomic adult population. The multimodal focus of treatment includes interactive group therapy, behavioral contracting, relapse prevention, and 12-step involvement. Research funded by the National Institute on Drug Abuse indicated both positive treatment outcome and significant cost efficacy. These results may be in some contrast to prevailing assumptions about public sector, government-operated behavioral health-care delivery to high-risk populations. Multiple variables for consideration in future outcome research are discussed, with potential for database inclusion toward standardization of treatment and cost protocols.

MODELS OF GERIATRICS PRACTICE: Decreased Hospital Utilization By Older Adults Attributable to a Home Hospitalization Program

To evaluate the cost effectiveness of a short-term home health care program for older people, Home Hospitalization (HH), compared with the alternative of regular ambulatory care with general or geriatric hospitalization as necessary. Our HH was initiated in November 1991 to serve Jerusalem residents. Program staff included physicians, nurses, and paramedical professionals. Other medical/hospital services were provided nonselectively by the general medical personnel of the various hospitals in Jerusalem. Patients over the age of 65 were either referred to the HH program (study group, n = 36,500) or to routine medical care (control group; n = 9000) depending on their Sick Fund assignment. Hospital utilization rates per enrollee were studied prospectively and compared both between the two groups and with hospitalization rates in the year before the initiation of the program. During the first 26 months of operations, the HH program cared for 741 older persons for a total of 37,290 days' care at an average daily costs of $30.06 (1992) and $23.64 (1993). Annual general hospitalization rates per person declined in the study group from 2.80 days in the 1991 baseline period to 2.65 days in 1992 and to 2.54 days in 1993. Hospitalization rates in the control group increased from 2.62 in 1991 to 2.70 days/member and 2.71 days/member in 1992 and 1993, respectively. Annual geriatric hospitalization rates declined considerably in the study group from the 1991 baseline of 1.49 to 1.34 (1992) to 1.33 (1993). The control group experienced a small decrease from 1.64 (1991) to 1.58 (1992) and then a rise to 1.68 days per member in 1993. For the 26-month duration of the program, estimated savings of 20,773 general hospital days ($5.54 million) and 8486 geriatric hospital days ($0.98 million) exceeded its costs ($0.97 million), providing a cost/benefit ratio of 5.7/1. In addition, patient satisfaction was high. The HH program provided a cost effective substitute for care in a geriatric or general hospital for Jerusalem's elderly.

Planning the development of cystic fibrosis gene carrier screening.

It is now possible to test individuals to assess their cystic fibrosis gene carrier status and a range of strategies for screening the population have been piloted. The objective of this research was to develop a planning framework which health care planners and purchasers can use to assess the overall quantifiable outcomes and direct costs resulting from a year of alternative screening strategies and the ways costs and outcomes evolve over time. Beyond broader ethical and clinical considerations the information provided by such a framework is needed to support decisions surrounding the development of screening programmes. Operational Research modelling techniques were used to develop the planning framework. To help illustrate the framework it was then used to assess the quantifiable outcomes and direct costs of three of the main alternative screening strategies: from antenatal clinics, '2-step' screening where females are tested first followed by a screening invitation to the partners of female carriers, and 'couple' screening where both partners must agree to be tested at the outset; and from primary practice clinics 'active' contact of attenders. Quantifiable outcomes are defined as the number of individuals informed of their carrier status and the number of carriers, carrier couples, and affected fetuses detected. Direct costs are those associated with the recruitment and testing of individuals and the subsequent counselling of any gene carriers or carrier couples identified. Results are based on services for a resident population of 250,000 at two time points, year one and a year at 'steady state'. The resultant framework estimates the number of individuals tested using data on the size of the target population, the proportion of that population alerted to the screening service, and the proportion who agree to be tested when approached. Given service users, prevalence data are used to assess service outcomes. Given the number of individuals approached and the subsequent demands for services, service costs can be estimated. Preliminary results indicate that in the short-term health care purchasers and planners who favour screening are likely to opt for antenatal strategies. Although the high coverage of the primary practice strategy leads to high outcomes in year one, relative to the antenatal strategies, it also leads to very high costs. At 'steady state', cost and outcome differences between the strategies are less marked. This paper provides a framework which can be used to provide information to support decision-making surrounding the development of screening services. The methodology fills an important void in the literature and complements research elsewhere by health economists and by geneticists and their research colleagues. Preliminary findings based upon use of the approach demonstrate the need for continued research to further refine and improve the methodology.

A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course.

Studies of the prevalence, natural history, and outcome of unrecognized mental illness in general medical outpatient settings were reviewed. Approximately half of the patients with a psychiatric disorder were not recognized as having a mental illness by their primary care physician. The natural history of unrecognized mental illness suggests a poorer clinical course of anxiety disorders but not for depressive disorders. Most interventions demonstrated a significant improvement in the physician's ability to identify and treat psychiatric disorders but had a minimal effect on patient symptoms and no effect on short-term health care use. Although primary care physicians do not recognize psychiatric disorders in a high percentage of patients, efforts to improve recognition may not lead to decreased patient suffering or decreased health care costs.

Longitudinal patterns and correlates of hormone replacement therapy use in middle-aged women.

Patterns of hormone replacement therapy (HRT) use over time and predictors of initiating or discontinuing use were examined in a longitudinal study. A cohort of 2,425 women aged 45-55 years identified from a population-based random survey in Massachusetts in 1981-1982 was followed by six telephone interviews, 9 months apart. Cohort participants were either premenopausal (66.8%) or in early perimenopause (33.2%). During the study, prevalence of use was low overall (12.3%) and was considerably higher for surgical menopause (45%) than for peri- (9.3%), natural (4.5%), or premenopause (1.5%). Predictors of HRT uptake and discontinuation (from time t - 1 to time t) were examined by repeated-measures logistic regression, stratified by surgical status. For surgical menopause, the only significant predictor of HRT uptake was recent surgery (odds ratio = 4.4; 95% confidence interval 2.73-7.22), while for nonsurgical subjects, menopausal status (primarily perimenopause), prior use of HRT, health care utilization, hot flashes, alcohol consumption, regular exercise, and leaner body mass were all significant predictors of uptake. Discontinuing HRT was inversely associated with surgical and perimenopause and positively related to prior short-term use and health care utilization. Nonsurgical HRT users had a somewhat more favorable cardiovascular risk profile than did nonusers.

Predictability of Individual Health Care Expenditures

It is widely believed in both academic and political circles that direct, uniform capitation payments to health insurers may induce them to contain costs. The premiumreplacing capitation payments should account for predictable variations in individual health care expenditures. This article describes a model that encompasses and rejects several previous models that have been proposed for analyzing these variations. The results indicate that, at most, 20 percent of the variance among individuals in annual, short-term health care expenditures is predictable.

Participation in a periodic physical examination program and group health care utilization and costs.

The authors identified 710 male employees of a multinational US corporation eligible to take periodic physical examinations for a consecutive 3-year period (1983 to 1985) and insured by one of the company's health insurers. Group health insurance claims rates and costs for the calendar year 1985 were studied among executives who did not take an examination during the study period, those who took it once or twice, and those who took it all 3 years. Health care utilization for those who did not participate in the program was significantly lower than both groups of participants. Average claim costs in 1985 among those who participated all 3 years ($1,039) was 1.77 times the cost of those who participated one or two times ($588) and 2.30 times the cost of those who did not participate ($452). We conclude that short-term health care utilization and costs are higher among participants than non-participants of a periodic physical examination program.

A conceptual model for the implementation of patient education in the general, short-term hospital

In general hospitals providing short-term health care, the process of patient education is influenced by both external and internal factors. Taking these into consideration, the author has developed a conceptual model for implementing patient education within this setting.