The mortality rate for coronary artery disease has decreased steadily over the past 25 yeas, attributable to a great extent to advances in medical and mechanical interventions. Nevertheless, mortality rates for acute coronary syndromes remain between 4% and 7%. This article highlights treatment options and the challenge of implementing evidence-based recommendations.
Antiplatelet agents are the standard of practice in the management of atherosclerosis and acute coronary syndrome. In contrast to the available antiplatelet agents, vorapaxar represents a novel mechanism of action. It is an antagonist of the platelet protease-activated receptor-1 and inhibits thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation. The Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-Thrombolysis in Myocardial Infarction 50 (TRA 2°P-TIMI 50) trial led to the approval of vorapaxar by the Food and Drug Administration and European Medicines Agency for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or peripheral arterial disease. TRA 2°P-TIMI 50 trial showed that the use of vorapaxar (2.5 mg once/daily) in addition to standard dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor was effective in the secondary prevention of recurrent thrombotic events among patients with previous atherothrombosis, particularly in patients with prior MI; at the expense of an increase in major bleeding. Another recently published Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor (VORA-PRATIC) study showed that among post-MI patients treated with potent P2Y12 inhibitors (prasugrel or ticagrelor), vorapaxar reduced platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin. The current review summarizes an up-to-date literature on pharmacokinetics, pharmacodynamics, and clinical efficacy of vorapaxar and proposes future directions of research.
Although the use of beta blockers has measurably improved the state of cardiac care in the United States, more work remains to be done. Other meritorious interventions for cardiovascular conditions that deserve attention by MCO's. Given the continuing clinical and and cost burden of heart disease, MCO's can use the lessons learned from the success of beta blockers in other important areas of cardiovascular care, including longer-term beta-blocker therapy, treatment of lipid disorders, and use of aspirin and thienopyridine derivatives.
The mortality rate for coronary artery disease has decreased steadily over the past 25 yeas, attributable to a great extent to advances in medical and mechanical interventions. Nevertheless, mortality rates for acute coronary syndromes remain between 4% and 7%. This article highlights treatment options and the challenge of implementing evidence-based recommendations.
Racial and ethnic disparities in cardiovascular care are greatly influenced by market factors and how the health care system is organized. This study examines key health system factors that contribute to disparities in cardiac care among racial and ethnic minorities in the United States. A market assessment, consisting of site visits, interviews, and data collection from key health care providers in 10 communities, was undertaken to identify common characteristics in the health care markets and to explore how these factors may drive disparities in cardiac care.
This study examines the use of bisphosphonates for treating Paget's disease of the bone through an analysis of drug, dose, and therapy-duration data. Data were obtained from a national, multi-managed care plan claims database (based on claims filed from 1996-2004). Patient eligibility criteria included at least one claim with Paget's disease International Classification of Diseases, Ninth Revision code 731.0, at least one bisphosphonate pharmacy claim, at least six months' continuous enrollment after initiating bisphosphonate therapy (index date), and no more than one claim for osteoporosis. The proportion of patients with bisphosphonate therapy extending beyond the initial recommended treatment regimen (incremental drug use) and associated costs were calculated for each drug. Of 433 patients with Paget's disease receiving bisphosphonate treatment (mean age, 65.0 yr; 64.3% women), 53.1% were prescribed alendronate at the index date; 34.9% and 7.4%, were prescribed risedronate and etidronate, respectively. More than 40% of patients with Paget's disease receiving at least one bisphosphonate were prescribed bisphosphonates beyond the recommended regimen duration at substantial incremental costs.
Texas Children's Health Plan (TCHP) redesigned its approach to care management in an effort to provide support for member-centric care and the medical home. The changes in process and structure focused on connecting information and programs to promote care for members in a collaborative manner and taking advantage of the synergy between staff, programming, and the physician practices serving health plan membership. The results brought about an improvement in job satisfaction, positive change in the medical-loss ratio, and new innovations to support preventive and chronic care service delivery needs of the TCHP membership.
A study group gathered by the Pharmacy & Therapeutics Society reviewed data on the Department of Veterans Affairs (VA) health care system's implementation of a new technology (insulin glargine) for patients with diabetes. It examined local implementation of VA criteria for nonformulary use of insulin glargine in 21 VA treatment facilities that were surveyed about the issue. The examination found differences in the use of insulin glargine across the 21 treatment facilities and in the approach to implementing the criteria for nonformulary use of insulin glargine used at the individual VA treatment facility level. Differences were identified regarding the respective roles of endocrinologists and PCPs in prescribing insulins, including insulin glargine. The study group urges further short- and long-term research to better understand the utilization, cost, and health outcome implications of the implementation process for the nonformulary criteria. Lessons learned from such research could benefit other health care systems and formulary committees.
The Medicare Prescription Drug Improvement and Modernization Act of 2003 offers prescription drug coverage through the Medicare part D program. However, the standard benefit does include a gap in coverage, commonly known as the "doughnut hole". This study, which included 90,615 subjects, aimed to evaluate the effect of the prescription drug coverage gap on drug utilization and expenditures. Beneficiaries in the study group were older (76.34 vs. 73.04 yr, P < .0001) and sicker (5.39 vs. 3.66 disease conditions, P < .0001) than those in the control group. They also incurred substantially higher out-of-pocket expenses ($2534 vs. $598, P < .0001) than the individuals in the control group. From the preperiod to the postperiod, the study group's average days of therapy decreased by 15.85% (from 1104 to 929, P < .0001), and total costs fell 28.02% (from $2441 to $1757, P < .0001). The average out-of-pocket costs increased by 88.94% (from $877 to $1657, P < .0001); in the control group, however, the average days of therapy increased by 1.77% (from 680 to 692), and total costs rose by 2.19% (from $1322 to $1351). Out-of-pocket costs decreased by 5.54% ($307 to $290). Using difference-indifference models, the Medicare part D prescription drug coverage gap was estimated to have reduced medication utilization by 187.49 days of therapy (P < .0001) while raising out-of-pocket costs by $796.49 (P < .0001) and increasing the generic utilization rate by 7.33% (P < .0001). Regular Medicare part D beneficiaries reduced medication utilization after they reached the coverage gap, which raises concerns those beneficiaries may face an increased risk of adverse health events.
To address the need to reduce psychiatric emergency-room (ER) recidivism and to promote continuity of care, this study developed a model using administratively obtainable variables to predict psychiatric ER visits in the six months following an index ER visit for a psychiatric condition. Data on member characteristics, preindex psychiatric ER use, index ER information, and postindex utilization for 1,029 adult HMO members visiting the ER for a psychiatric condition were collected and randomly divided in half. A regression model predicting psychiatric ER visits in the six months following the initial psychiatric ER visit was developed in the first data set and tested in the second. In both models, Medicaid insurance coverage, and preindex inpatient admissions for depression or substance abuse were identified as significant predictors of future psychiatric ER utilization. Administratively identifiable variables can be used to identify members at elevated risk of ER recidivism for psychiatric conditions. Through improved identification of risk, case management interventions can be strategically directed to members with the greatest need of services.
To assess the effect of a disease management program in anemia of chronic kidney disease (CKD), the authors reviewedthe records of all adults treated with epoetin alfa (EPO) at their institution between September 2003 and April 2006 and compared them with a group treated through a pharmacist-managed program with patients managed by PCPs in terms of time to target hemoglobin (Hb) (11-12.9 mg/dL), percent of Hb values maintained in target range, average weekly dose of EPO, and percent of iron-saturation (T-sat) values within target range (20%-50%) over a period of six months to one year. Although pharmacist-managed patients received lower weekly EPO doses than those managed by PCPs (6,698 vs. 12,000 units, respectively; P = .0001), they achieved goal Hb faster (47.5 vs. 62.5 days, P = .11) and maintained a higher percentage of Hb and T-sat values in target range (69.8% vs. 43.9%, P = .0001, and 64.8% (vs. 40.4%, respectively; P = .043). A pharmacist-managed program may present significant clinicaland economic benefits in anemia of CKD.
Oral antibiotic therapy can reduce complications and costs compared with intravenous (IV) therapy. The object of this study was to determine the health economic and resource utilization effects of outpatient treatment with oral linezolid relative to IV vancomycin. Longitudinal claims data from 80 health care plans were used. Patients 18 years and older, who did not have osteomyelitis, with a pharmacy claim for linezolid or vancomycin between January 1, 2002 and March 31, 2004 were eligible. Clinical and resource utilization data were collected for 12 months before and 35 days after treatment. Patients treated with linezolid were matched with controls treated with vancomycin, based on propensity scoring. Direct medical costs paid by health plans were compared. A total of 1,048 matched pairs were identified. Demographic and clinical characteristics were comparable between groups. Patients with linezolid claims had lower resource utilization versus those with vancomycin claims during follow-up, including fewer mean physician office visits (4.1+/-5.7 vs. 8.4+/-13.8 visits; P< .001); lab/diagnostic claims (6.3+/-18.0 vs. 10.4 +/-15.2 claims; P< .001); pharmacy claims (7.3+/-8.1 vs. 13.6+/-17.4 claims; P< .001); emergency room visits (9.7% vs. 13.9%; P= .003) and hospitalization (15.3% vs. 19.1%; P= .024). Patients receiving vancomycin were more likely to be hospitalized or have an emergency room visit than patients receiving linezolid. Mean total adjusted cost was 4,707 dollars less for linezolid compared with vancomycin (8,401dollars vs. 13,108 dollars; P< .001). Similar trends were observed for patients matched based on complicated skin and soft tissue infection diagnosis. Outpatient treatment with oral linezolid was associated with significantly lower resource utilization and total medical costs compared with IV vancomycin.
This study sought to determine the correlation between a health plan's Health Plan Employer Data and Information Set (HEDIS) score for glycated hemoglobin (HbA1c) control in patients with diabetes and its utilization of analog insulin, human insulin, and oral drug therapy as determined by the share of prescriptions of each therapy. Prescription volumes were tracked for four categories of diabetes drug therapy: (1) analog insulin, (2) human insulin, (3) single-source brand oral products, and (4) multisource generic oral products, for the three months ending January 2005 and January 2006 and matched to the 2004 and 2005 HEDIS scores. A correlation analysis conducted between the HbA1c-based HEDIS score and the prescription share of each drug category found a favorable and statistically significant (P < .0001) correlation between plan HbA1c HEDIS score and plan prescription share of analog insulin in both 2004 and 2005. The correlation between HEDIS scores and human insulin was not statistically significant. Unfavorable correlations were found between HEDIS scores and both the single-source brand and the multisource generic oral category prescription shares, although these correlations were found to be significant only for the single-source products in 2005.
The goal of this study was to quantify the incremental direct medical and indirect work-loss costs associated with patients diagnosed with atopic dermatitis (AD). A de-identified administrative claims database was used comprising 5.1 million covered beneficiaries from 31 Fortune 500 self-insured employers between 1998 and 2005. Patients with at least two AD diagnosis claims (N = 13,749) were compared with three matched controls (based on yr of birth and gender) with no AD diagnosis (N = 41,247). In addition, a multivariate two-part regression analysis was used to isolate the cost increase attributable to AD by controlling for confounding factors such as age, gender, health plan type, comorbidities, organ transplantation, industry of employer, region, and year. Direct medical and indirect work-loss costs for the AD group were higher on average by $88 and $64 per patient per month, respectively (both P< .001). After multivariate adjustment, the total incremental cost per patient per month for the AD group was $83 (direct: $52, P< .001; indirect: $31, P< .001). Employer-payers experience a significant annual cost burden of $991 per patient attributable to AD. Employee disability and increased sick days account for 38% of the cost burden.
