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Biomedical subjects

C Daniel Mullins

Publications and source records attributed to C Daniel Mullins.

At least 55 records · Page 3Linked to original sources
PubMed2003

Exploring donors' and recipients' attitudes about living donor kidney transplantation.

CONTEXT: There is a growing interest in living donor kidney transplantation because of its potential to reduce the current kidney shortage. OBJECTIVE: To explore the experience of potential recipients, recipients, potential donors, and donors with regard to living donor kidney transplantation and laparoscopic living donor nephrectomy. METHOD: Twenty-five patients participated in a series of focus group interviews. The interviews were tape-recorded and a content analysis was performed. RESULTS: All participants had a positive attitude toward living donor kidney transplantation and laparoscopic living donor nephrectomy, though this procedure was not a factor that influenced potential donors' decision to donate a kidney. None of the potential donors and donors felt coerced into giving a kidney; they were motivated by a desire to help a loved one who was suffering. The main perceived impediment to donate a kidney was the potential recipients' reluctance to accept the offer. Potential recipients and recipients found it difficult to ask for a kidney and worried about the consequences of a kidney removal on their donor's health. A potential barrier to living donor kidney transplantation was that recipients would never have accepted a kidney if their donor had to pay for the kidney removal. In addition, recipients believed that a kidney from a non-blood-related donor was not as a good a match as a kidney from a blood-related donor. CONCLUSION: This exploratory study reveals that donors, potential donors, recipients, and potential recipients had an overall positive attitude toward living donor kidney transplantation and laparoscopic living donor nephrectomy. This study also sheds light on a number of barriers that have not been previously reported.

Adult↗
PubMed2003

Major components of the direct medical costs of alpha1-antitrypsin deficiency.

STUDY OBJECTIVES: To examine the sources of the direct medical costs of alpha(1)-antitrypsin (AAT) deficiency based on survey data from affected individuals. BACKGROUND: Prior research has reported the total cost of AAT deficiency but has not examined the specific components of the direct medical costs of affected individuals. METHODS: In order to detail the sources of the direct medical costs, we sent surveys to 688 respondents of a previous survey. We estimated the costs in three ways, which differed in the method of managing missing values. With method 1, the group mean value of cost per unit of utilization, multiplied by the occurrences of utilization, was used to replace the missing value. Two sensitivity analyses (ie, methods 2 and 3) were conducted to test the robustness of our estimate. With method 2, values of zero were entered for all missing values. With method 3, the missing values were replaced by the group mean value. The Wilcoxon test was used to test the cost differences between patients of different phenotypes. All cost data were expressed in 1998 US dollars. RESULTS AND CONCLUSIONS: Two hundred ninety-two individuals responded to the survey. The annual total health-care costs were high (mean range, $36,471 to $46,114 US dollars; median range, $12,485 to $37,100 US dollars [according to the method for managing missing data]) for AAT deficiency. The total costs for individuals with the PI*ZZ phenotype exceeded those for individuals with a non-PI*ZZ phenotype. The use of IV augmentation therapy accounted for more than half of all direct medical costs for the respondents. Besides the costs for therapy with alpha(1)-proteinase inhibitor (Prolastin; Bayer; West Haven, CT), other major cost sources were prescription drugs other than alpha(1)-proteinase inhibitor, hospitalization, health insurance, and physician visits.

Adult↗
PubMed2003

A Medicaid population's use of physicians' offices for dental problems.

OBJECTIVES: This study evaluated how the elimination of Medicaid reimbursement to dentists for the treatment of adult dental problems affected patients' visits to physicians. METHODS: Data tapes describing physicians' claims for adult Medicaid patients were obtained from the Maryland Medicaid Management Information System. The database contains information on all claims made to Maryland Medicaid, including date, provider, International Classification of Diseases, Ninth Revision, Clinical Modification Manual code, and payments. RESULTS: A total of 5334 individuals made physician's office claims related to dental problems sometime during the 4-year study period. The rate of dental-related claims by physicians decreased by 8% after the policy change. CONCLUSIONS: Visits to physicians' offices decreased even though an increase might have been expected because of the elimination of access to dentists in private practice. Patients might have assumed that if visits to dentists would no longer be paid for, neither would visits to physicians' offices.

Adult↗
PubMed2002

Resources and use of the intensive care unit in patients who undergo surgery for ovarian carcinoma.

BACKGROUND: The objective of the current study was to determine the association of age, comorbid illness, and length of stay (LOS) in the intensive care unit (ICU) in women who underwent oophorectomy for ovarian carcinoma. METHODS: The authors conducted a population-based analysis of all women with a primary or secondary diagnosis of ovarian carcinoma who underwent oophorectomy between 1994-1999. Chi-square tests and Student t tests were used to determined differences in means or proportions. Multivariate regression methods were used to build predictive models. RESULTS: Of 8109 women who were admitted, 1412 women underwent oophorectomy, 1045 of 1412 women (74%) underwent hysterectomy, 325 of 1412 women (23%) underwent intestinal surgery, and 296 of 1412 women (21%) were admitted to the ICU. Overall (+/- standard deviation) LOS was 8.3 days +/- 6.90 days, and the total charges were $16,675 +/- $15,590 (1999 dollars). Patients who underwent intestinal surgery were older (62.5 years vs. 57.1 years; P = 0.01), had a longer LOS (11.62 days vs. 7.33 days; P = 0.01), had a longer ICU stay (1.15 days vs. 0.58 days; P = 0.01), and had a higher mean Charlson Comorbidity Index (CCI) (16.01 vs. 8.73; P = 0.01) compared with patients who did not undergo intestinal surgery. Multivariate regression analysis revealed that age, intestinal surgery, CCI, ICU stay, and African-American race were associated with LOS and contributed indirectly to total charges, whereas age and ICU say were the two most important direct determinants of total charges. CONCLUSIONS: Advancing age, ICU stay, intestinal surgery, African-American race, and comorbid illness were the most prominent predictors of LOS, whereas age and ICU stay were the most important factors predicting total charges in women who underwent oophorectomy for ovarian carcinoma.

Adult↗
PubMed2002

Use of ICD-9 coding as a proxy for stage of disease in lung cancer.

OBJECTIVE: To determine the validity of using ICD-9-CM codes indicating metastases as a proxy to classify lung cancer patients by stage of disease. RESEARCH DESIGN: This retrospective database analysis used diagnosis codes to classify subjects to either localized or advanced-stage disease and then compared this classification to the tumor registry staging, which was considered as the 'gold standard.' SUBJECTS AND MEASURES: Study subjects included all lung cancer patients treated at our academic institution during 1996-1997, who were also members of a large insurance company. Data were derived from inpatient cancer-related claims linked with our institution's tumor registry data. Advanced-stage disease (stages II to IV) was defined by claims indicating lymph node involvement or metastases (ICD-9 codes 196-199.1). The tumor registry stagings of the disease for these patients were clustered into two groupings, stages 0-I (localized) and stages II-IV (advanced). RESULTS: Tumor registry entries were identified for 66/77 (85.7%) patients. A total of 19 out of 22 local disease patients (sensitivity of 86.4%) and 30 out of 44 advanced disease patients (sensitivity of 68.2%) were classified correctly by ICD-9 code. A total of 19 out of 33 patients with local disease codes (PPV of 57.6%) and 30 out of 33 patients with advanced disease codes (PPV = 90.9%) were properly identified. CONCLUSIONS: For a population of lung cancer patients in an academic institution who were under a private insurance plan, the ICD-9 coding was associated with a sensitivity and positive predictive values that were consistent with previously reported estimates using Medicare-SEER data. The use of such data to classify patients to disease stages should be executed with caution as under-reporting might exist. Continued attention to discharge abstracting will be needed to improve the validity of this technique.

Humans↗
PubMed2002

Resource utilization for patients undergoing hysterectomy with or without lymph node dissection for endometrial cancer.

OBJECTIVE: The objective was to study the association of age, comorbid illness, race, and type of hospital with resource use in patients undergoing hysterectomy and lymph node dissection for endometrial cancer. METHODS: The study was a population-based analysis of patients undergoing hysterectomy with a diagnosis of endometrial cancer in Maryland 1994-1996. Chi-square and t tests determined differences in means or proportions. Multivariate logistic regression methods were used to build predictive models. RESULTS: The 1281 women underwent total abdominal hysterectomy, 91%; total vaginal hysterectomy, 6%; radical hysterectomy, 2.5%, laparoscopically assisted total vaginal hysterectomy, 0.3%; 32% also underwent lymph node dissection. Neither age, nor race, nor comorbid illness influenced admission to teaching hospitals. Co-morbidity was documented in 56% of cases. African Americans were more likely to have one (P = 0.002) or >1 co-morbid illness (P = 0.045) than Caucasians. The most common complications were anemia (13.6%), infection/fever (12%), cardiac (9.4%), pneumonia (8%), ileus (5%), and bowel obstruction (5%). These complications occurred with higher frequency in teaching hospitals (P = 0.0001), In large hospitals (P = 0.0001), and in African American patients compared to Caucasians (P = 0.028). Multivariate regression analysis revealed that older age, admission to teaching or large hospitals, lymph node dissection, heart disease, and African American race were associated with significantly higher resource use. CONCLUSION: We documented age and racial/ethnic differences in comorbid illness, complications, and resource utilization for patients undergoing hysterectomy for endometrial cancer. The differences in resource use for teaching hospitals may be reflective of the severity of complications, which are indirectly determined by length of stay. Given the higher costs and skills required to care for elderly women with comorbid disease and complications, quantification of the complexity of care is of utmost importance for allocation of sufficient resources for the care of women with endometrial cancer.

Adult↗
PubMed2002

Dental visits to hospital emergency departments by adults receiving Medicaid: assessing their use.

BACKGROUND: Pain from toothaches represents a significant problem. People lacking access to private dental services may use hospital emergency departments, or EDs. In 1993, Maryland eliminated Medicaid reimbursement to dentists for adult emergency services. METHODS: The authors used the change in Medicaid policy that eliminated dentist reimbursement to establish two study periods. Data tapes describing patients' use of EDs were obtained from the Maryland Medicaid Management Information System. A total of 3,639 people visited EDs for dental problems sometime during the four-year study period. RESULTS: After controlling for age, race and sex, the authors found that the rate of ED claims was 12 percent higher in the postchange period than in the prechange period. Comparisons between periods show significant rate increases during the postchange period for men, whites, African-Americans and patients aged 21 through 44 years and 45 through 64 years. CONCLUSIONS: The change in Medicaid policy that eliminated dentist reimbursement and participation in the program appears to have increased the use of EDs for the treatment of dental problems. Practice Implications. Many EDs lack dental services and are not capable of providing definitive treatment. When definitive treatment is not provided, this pattern of care may be repeated if patients are forced to return for treatment.

Adult↗
PubMed2002

Pharmacy benefit management: enhancing the applicability of pharmacoeconomics for optimal decision making.

Previous research indicates that in order to make pharmacoeconomic information applicable and useful for pharmaceutical benefit management (PBM) companies, several aspects need to be considered and improved. These include: timely availability of information, head-to-head comparators, peer-reviewed publications, independent sponsorship of pharmacoeconomic studies, use of relevant populations in research and published pharmacoeconomic models, and pharmacoeconomics training for pharmaceutical companies' sales personnel. In addition to these measures, guidelines have been playing an important role in improving the applicability of pharmacoeconomic information. This paper examines the progress to date in enhancing the applicability of pharmacoeconomics for optimal PBM decision making. The greatest improvements have been made in enhancing the quality of pharmacoeconomic research and the quality of peer-reviewed publications. Direct comparator studies are starting to emerge, but in limited numbers. The need for additional training of pharmaceutical representatives and PBM staff members remains a critical issue.

Cost-Benefit Analysis↗
PubMed2002

Discontinuation rates of topical glaucoma medications in a managed care population.

BACKGROUND: Rates of medication discontinuation reflect factors including effectiveness, tolerability, cost, and dosing frequency. Discontinuation data can be useful to physicians and health plan managers as they compare various glaucoma medications. OBJECTIVE: To compare rates of discontinuation of therapy in patients initially prescribed monotherapy with a topical glaucoma medication. METHODS: Members of a managed care plan who filled at least 1 prescription for latanoprost, timolol, or brimonidine during a 30-month period were eligible to participate in this study. Prescription refill records for all glaucoma agents used in the plan were extracted for the study period. Rates of discontinuation of initial glaucoma therapy were compared using Cox regression methods; Kaplan-Meier survival curves were generated. RESULTS: A total of 72,744 prescriptions were eligible, of which 48491 were for study drugs. Latanoprost was the most frequently dispensed therapy (accounting for 49.7% of study drugs), followed by timolol (30.6%), and brimonidine (19.6%). After inclusion and exclusion criteria were applied, 2283 patients were included in analyses. Latanoprost-treated patients were significantly less likely to discontinue medication than were those treated with timolol or brimonidine. Kaplan-Meier survival curves confirmed that latanoprost-treated patients exhibited the greatest persistency with therapy. CONCLUSION: In this managed care setting, rates of discontinuation in patients initially treated with latanoprost were lower than those of patients receiving comparator drugs.

Administration, Topical↗
PubMed2002

Cost effectiveness of kinetic therapy in preventing nosocomial lower respiratory tract infections in patients suffering from trauma.

Studies show that kinetic therapy (KT) reduces the incidence of early pneumonia and other complications, and shortens hospital length of stay. Using decision-tree software in a retrospective analysis of one investigator's clinical data, the authors sought to determine if KT is cost effective for preventing nosocomial pneumonia and other complications in patients with critical illnesses. This analysis revealed that KT yielded 202 fewer infections per 1,000 patients suffering trauma--a cost savings of $6,695 per patient compared with standard care. On this basis, they conclude that prophylactic KT is cost effective and should be considered for at-risk patients in the critical care setting.

Beds↗
PubMed2002

Health disparities research--a model for conducting research on cancer disparities: characterization and reduction.

The existence of disparities in health has gained national attention. While racial disparities in health have been documented for decades, "health disparities research" has not been described or defined. Health disparities may occur in categories such as racial/ethnic, age, and in geographic categories such as rural/urban, as well as in socioeconomic status. This paper, using the documented racial disparities in cancer for blacks and whites, presents a framework and model for documenting disparities, designing and conducting health disparities research, and applying the results of this research to reduce or eliminate disproportionate rates. The model consists of four components: 1. Surveillance 2. Explanatory Research 3. Intervention Research: Development and Evaluation 4. Translation/Application of Research Results. This model is presented to assist researchers in systematically addressing health disparities through well designed, well conducted, and well applied research. The Special Populations Cancer Research Networks are an 18 member national network of grants that focus on cancer disparities research, community awareness and participatory research, increased accrual of minorities to clinical trials, and training of minority investigators. The primary objective of the University of Maryland School of Medicine's grant is to reduce cancer rate disparities in underserved communities.

Black or African American↗
PubMedDate not supplied

Comparing cost-effectiveness analyses of anti-hypertensive drug therapy for decision making: mission impossible?

The purpose of this literature review was to compare the methodology used in the most recently published cost-effectiveness studies of antihypertensive treatments, and to identify methodological strengths and weaknesses that indicate the study's potential as a useful, decision-making tool. Based on the results of a search of several databases, spanning the years 1995 to 2000, 10 cost-effectiveness studies were identified. Although the majority of the studies reported their cost-effectiveness ratio in "costs per year of life gained," the studies also considered a varying range of components including additional end points. The methodology used to measure effectiveness, the cost variables included, and the characteristics of the patient population varied significantly across studies. Due to this lack of conformity, it would be difficult, if not impossible, to compare the results and draw conclusions about the relative cost-effectiveness of different types of antihypertensive drug therapies. This lack of uniform comparison across studies is likely to draw criticism from both the clinical and health-care decision-making communities. Future studies within this field should be thorough and useful for decision making. It is suggested that short-term outcomes should include systolic and diastolic blood pressure measurements and long-term outcomes should include end points such as myocardial infarction, stroke, congestive heart failure and renal events. Other positive outcomes such as a more favorable side-effect profile, should be used to enhance the primary outcomes. Additionally, when subpopulations are considered in submodels, studies should address the issue of generalizability. Cost calculations should be transparent and related to the perspective of the study. Modeling the cost-effectiveness of a drug may be an acceptable method provided that data sources and assumptions are valid and transparent.

Adult↗
PubMedDate not supplied

Cost-effectiveness of rosuvastatin compared with other statins from a managed care perspective.

OBJECTIVE: The objective of this study was to identify the most cost-effective statin or combination of statins, from the perspective of a managed care payer. METHODS: A decision-analytic model compared the cost-effectiveness of titration to goal with atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin in patients with elevated low-density lipoprotein cholesterol (LDL-C). Effectiveness measures included the percentage change from baseline LDL-C and high-density lipoprotein cholesterol (HDL-C), and the percentage of patients achieving National Cholesterol Education Program (NCEP) Second Adult Treatment Panel (ATP II) LDL-C goals. Direct medical costs were calculated based on drug, physician, and laboratory resource use, multiplied by wholesale acquisition costs for drugs and the 2005 Medicare reimbursement rates for services. A Monte Carlo simulation tested the sensitivity of results to model efficacy inputs. RESULTS: In the base-case analysis, rosuvastatin dominated atorvastatin, pravastatin, and simvastatin. Generic lovastatin dominated fluvastatin. The incremental (absolute) reduction in LDL-C, increase in HDL-C, and increase in patients to goal with rosuvastatin compared with lovastatin were 16%, 3%, and 27%, respectively. Incremental costs per additional 1% reduction in LDL-C, 1% increase in HDL-C, and patient to goal with rosuvastatin versus lovastatin were $8, $41, and $436, respectively. A wide variety of assumptions were assessed and Monte Carlo sensitivity analyses were conducted. Findings were most sensitive to the cost of lovastatin. CONCLUSION: Rosuvastatin dominates atorvastatin, pravastatin, and simvastatin because it is more effective and less costly, and it may be considered cost-effective compared with generic lovastatin. The most cost-effective two-statin formulary contained lovastatin and rosuvastatin.

Adult↗
PubMedDate not supplied

An economic evaluation of triptan products for migraine.

OBJECTIVE: A composite outcome measure in migraine treatment assessment is useful to clinical decision-makers and payers as it can provide a more accurate reflection of effectiveness and allows for more complete modeling of economic value. The objective of this study was to compare the total triptan cost to treat 100 migraine patient attacks and the cost per successfully treated patient (CPSTP) for six marketed triptans using a composite measure of effectiveness, the "successfully treated" migraine (defined as requiring only one triptan dose to treat one migraine attack during a 24-h period). METHODS: This analysis was conducted from the perspective of the payer. Clinical data were abstracted from a rigorous, published meta-analysis. Two-hour response and pain-free response were used in conjunction with the recurrence rate reported in the meta-analysis to calculate the number of doses used by treatment successes and failures. The average wholesale price per dose was then used to calculate total triptan cost. RESULTS: Of the nine oral triptan doses compared, eletriptan 40 mg was associated with both the lowest total triptan cost for treating 100 migraine attacks ($1560) and with the lowest CPSTP ($56.39). CONCLUSIONS: The relative CPSTP rankings for migraine therapies are dependent on the definition of treatment success and relative pricing. The results of this study support the use of eletriptan for the treatment of acute migraine based on the model assumptions. This study can be used to assist in formulary considerations and offers a model that can be adapted by health-care decision-makers.

Drug Costs↗
PubMedDate not supplied

White paper: value of specialty certification in pharmacy.

OBJECTIVE: To address the value of Board of Pharmaceutical Specialties (BPS) certification, particularly as perceived by different stakeholders (pharmacists, employers, government, and academia), and to draw a parallel between specialization and certification in pharmacy and in medicine. DATA SOURCES: Electronic databases (Medline, International Pharmaceutical Abstracts, Sociological Abstracts), associations/health care organizations Web sites, outside reports, and clinical pharmacists involved in certification processes. STUDY SELECTION: Studies and reports that addressed the value of specialty certification were selected by the authors. DATA EXTRACTION: By the authors. DATA SYNTHESIS: Pharmacists with specialty certification report enhanced feelings of self-worth, improved competence, and greater marketability. Other values of certification include increased acceptance by health care professionals, salary increases, and job promotions. Employers have acknowledged board-certified pharmacists through public recognition, increase in responsibility, and some types of monetary compensation. In some governmental organizations, certified pharmacists receive salary raises and are granted prescribing authority. However, the overall value of specialty certification in pharmacy as perceived by the public or payers lags behind when compared with the status of specialty certification in medicine. CONCLUSION: Board-certified pharmacists appreciate the value of pharmacy specialty certification, and in a number of organizations and practice settings, board-certified pharmacists are perceived as valuable. Still, unlike board-certified physicians, board-certified pharmacists are not widely recognized outside or even within the pharmacy profession. To address this challenge, board-certified pharmacists ought to market their services to assure that other stakeholders recognize their value.

Accreditation↗
PubMedDate not supplied

Prescription drug spending trends for the privately insured in Maryland, 2000-2001.

Out-of-pocket drug spending per patient rose 25 percent in 2001 for the privately insured nonelderly in Maryland, outpacing the 10 percent increase in total drug spending per patient. Prescription drug use patterns changed little in response to a 30 percent rise in copayments, with the number of prescriptions per patient decreasing by 3 percent, and the proportion of generic drugs remaining steady. About 23 percent of patients spent less than 50 dollars on drugs in 2001, while 21 percent spent more than 700 dollars. Findings suggest that a greater proportion of the economic burden of prescription drugs in coming years will be borne by those who use them.

Adolescent↗
PubMedDate not supplied

Variability and growth in spending for outpatient specialty pharmaceuticals.

Specialty pharmaceuticals are a unique group of drug agents used to treat complex clinical conditions. Many specialty pharmaceuticals are biological in nature and administered through injection or infusion. Tracking spending on these pharmaceuticals is complex, because these products may be processed as either medical or pharmacy claims. This benchmarking study of ten Blue Cross Blue Shield plans, representing almost eighteen million covered lives, documents large expenditures on select specialty pharmaceutical categories and much variation in spending across plans, age groups, and time. Our results underscore the need for insurers to scrutinize trends in specialty pharmaceutical spending and identify appropriate management strategies.

Adult↗