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Biomedical subjects

Elizabeth A Chrischilles

Publications and source records attributed to Elizabeth A Chrischilles.

18 recordsLinked to original sources
PubMed2006

Hip fracture risk among community-dwelling elderly people in the United States: a prospective study of physical, cognitive, and socioeconomic indicators.

OBJECTIVES: We determined risks of short-term (2-year) hip fracture in a nationally representative, prospective cohort of community-dwelling elderly people 70 years or older. METHODS: We used self-report data from 2 waves of the Asset and Health Dynamics Survey (n = 5630). Sample-weighted logistic regression analyses were conducted to determine risk of hip fracture in relation to several demographic, cognitive, physical, and socioeconomic indicators. RESULTS: During the 2-year study period, 102 participants reported a new hip fracture. Several indicators of physical functioning and cognitive status, including incorrect delayed word recall and inability to lift 10 lbs (4.5 kg), were significantly associated with hip fracture risk. In the final model, mobile home residents, individuals without Medicare part B insurance, and those without a high-school diploma were at more than a 2-fold risk of hip fracture. Educational level, physical functioning, and insurance status were the top 3 contributors to hip fracture risk. CONCLUSIONS: In addition to functional status measures, health insurance status, educational level, and type of residence appear to be independent predictors of hip fracture.

Activities of Daily Living↗
PubMed2006

Population-based assessment of hospitalizations for neutropenia from chemotherapy in older adults with non-Hodgkin's lymphoma (United States).

OBJECTIVE: To study neutropenia hospitalization (NH) incidence and risk factors in a population-based sample of older adults with non-Hodgkin's lymphoma (NHL) and evaluate the validity of inferences from Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases. METHODS: NHL cases receiving first-course chemotherapy were identified from Iowa SEER-Medicare. Survival methods evaluated NH risk factors. Medical record and Medicare claims data on chemotherapy and NH were compared. RESULTS: Of 761 subjects, 165 (21.7%, 95% CI: 18.8, 24.6) were hospitalized for neutropenia. Of those hospitalized, 41% were hospitalized in cycle 1 and 22% in cycle 2. Significant multivariable risk factors for NH were diffuse large cell histology, renal disease, Charlson comorbidity index, and anthracycline chemotherapy but not patient age. Medicare and medical records agreed on month of chemotherapy initiation 95% of the time and chemotherapy type 95% of the time. ICD-9 code 288.0 sensitivity for NH was 80%. CONCLUSIONS: Neutropenia hospitalizations were common in the first 2 chemotherapy cycles, especially among older adults with comorbidity. Findings conflict with a prior medical records study in which age was a risk factor for NH and dose intensity a negative confounder. Valid inferences about age effects on chemotherapy toxicity require more clinical detail than is available in administrative data.

Adult↗
PubMed2006

Effect of dialysis center profit-status on patient survival: a comparison of risk-adjustment and instrumental variable approaches.

OBJECTIVE: To compare the estimated effects of dialysis center profit status on patient survival using alternative estimation strategies with retrospective data. DATA SOURCES/STUDY SETTING: Patient and provider-level retrospective data from the United States Renal Data System (USRDS), 1996-1999. STUDY DESIGN: Observational risk adjustment and instrumental variable methods. DATA COLLECTION/EXTRACTION METHODS: Study collected measures from various USRDS files describing clinical characteristics, survival, and the profit status of the initial dialysis center for incident end-stage renal disease (ESRD) patients aged 67+. USRDS facility files were used to assess dialysis center profit status and measure patient distances to dialysis centers. PRINCIPAL FINDINGS: Found survival effect related to profit status in the range of previous research using risk-adjusting covariates similar to those used in previous models. Adding further risk-adjusting covariates halved this effect. The relative proximity of for-profit and nonprofit dialysis centers to the patient residence was the strongest determinant of the profit status of the patient's initial dialysis center. The effect of profit status on survival was eliminated using the two-stage least squares variant of instrumental variable estimation with the relative proximity of for-profit and nonprofit dialysis centers to the patient's residence as the instrument. CONCLUSIONS: Using only the variation in initial dialysis center profit status that was related to the relative proximity of for-profit and nonprofit dialysis centers to the patient, we found no relationship between dialysis center profit status and patient survival. These results are in contrast to results obtained using risk-adjustment methods with a limited set of risk-adjusting covariates.

Aged↗
PubMed2005

Asthma and farm exposures in a cohort of rural Iowa children.

Epidemiologic studies of farm children are of international interest because farm children are less often atopic, have less allergic disease, and often have less asthma than do nonfarm children--findings consistent with the hygiene hypothesis. We studied a cohort of rural Iowa children to determine the association between farm and other environmental risk factors with four asthma outcomes: doctor-diagnosed asthma, doctor-diagnosed asthma/medication for wheeze, current wheeze, and cough with exercise. Doctor-diagnosed asthma prevalence was 12%, but at least one of these four health outcomes was found in more than a third of the cohort. Multivariable models of the four health outcomes found independent associations between male sex (three asthma outcomes), age (three asthma outcomes), a personal history of allergies (four asthma outcomes), family history of allergic disease (two asthma outcomes), premature birth (one asthma outcome), early respiratory infection (three asthma outcomes), high-risk birth (two asthma outcomes), and farm exposure to raising swine and adding antibiotics to feed (two asthma outcomes). The high prevalence of rural childhood asthma and asthma symptoms underscores the need for asthma screening programs and improved asthma diagnosis and treatment. The high prevalence of asthma health outcomes among farm children living on farms that raise swine (44.1%, p = 0.01) and raise swine and add antibiotics to feed (55.8%, p = 0.013), despite lower rates of atopy and personal histories of allergy, suggests the need for awareness and prevention measures and more population-based studies to further assess environmental and genetic determinants of asthma among farm children.

Adolescent↗
PubMed2005

Hospital volume-outcome relationships among medical admissions to ICUs.

BACKGROUND: Positive relationships between hospital volume and outcomes have been demonstrated for several surgeries and medical conditions. However, little is known about the volume-outcome relationship in patients admitted to medical ICUs. OBJECTIVE: To determine the relationship between hospital volume and risk-adjusted in-hospital mortality for patients admitted to ICUs with respiratory, neurologic, and GI disorders. DESIGN: Retrospective cohort study. SETTING: Twenty-nine hospitals in a single metropolitan area. PATIENTS: Adult ICU admissions from 1991 through 1997. METHODS: Using Cox proportional hazards models, we compared in-hospital mortality between tertiles of hospital volume (high, medium, and low) for respiratory (n = 16,949), neurologic (n = 13,805), and GI (n = 12,881) diseases after adjusting for age, gender, admission severity of illness, admitting diagnosis, and source. Severity of illness was measured using the APACHE (acute physiology and chronic health evaluation) III methodology. RESULTS: Among respiratory and neurologic ICU admissions, hazard ratios were similar (p > or = 0.05) in patients in low-, medium-, and high-volume hospitals. However, among GI diagnoses, risk of mortality was lower in high-volume hospitals, relative to low-volume hospitals (hazard ratio, 0.68; 95% confidence interval [CI], 0.54 to 0.85; p < 0.001), and was somewhat lower in medium-volume hospitals (hazard ratio, 0.83; 95% CI, 0.68 to 1.01; p = 0.06). Among subgroups based on severity of illness, high-volume hospitals had lower mortality, relative to low-volume hospitals, among sicker patients (APACHE III score > 57) in the respiratory cohort (hazard ratio, 0.77; 95% CI, 0.59 to 0.99) and the GI cohort (hazard ratio, 0.67; 95% CI, 0.53 to 0.85). CONCLUSIONS: Associations between ICU volume and risk-adjusted mortality were significant for patients with GI diagnoses and for sicker patients with respiratory diagnoses. However, associations were not significant for patients with neurologic diagnoses. The lack of a consistent volume-outcome relationship may reflect unmeasured patient complexity in higher-volume hospitals, relative standardization of care across ICUs, or lack of efficacy of some accepted ICU processes of care.

APACHE↗
PubMed2005

Effect of clinical characteristics on neutropenia-related inpatient costs among newly diagnosed non-Hodgkin's lymphoma cases during first-course chemotherapy.

STUDY OBJECTIVE: To estimate the costs of hospitalization for neutropenia among chemotherapy-treated patients with newly diagnosed non-Hodgkin's lymphoma and to assess baseline patient factors associated with these costs. DESIGN: Retrospective cohort study. DATA SOURCE: Linked Surveillance, Epidemiology, and End Results Program-Healthcare Cost and Utilization Project databases for Iowa from 1993-1998. PATIENTS: Patients with newly diagnosed non-Hodgkin's lymphoma who received all inpatient care at Iowa hospitals during their first course of chemotherapy. MEASUREMENTS AND MAIN RESULTS: Neutropenia-related hospitalization costs were estimated from discharge abstracts found within the earliest of the following: 6 months after the diagnosis month, the date of bone marrow transplantation, or date of death. We performed univariate tests of differences in neutropenia-related hospitalization costs in all patients in the sample, as well as tests for neutropenia-related hospitalization costs, length-of-stay, and cost/inpatient day for patients with at least one hospitalization for neutropenia. We modeled total inpatient charges over the period for patients with at least one neutropenia-related hospitalization (multiple regression). A total of 1636 patients with non-Hodgkin's lymphoma had chemotherapy in Iowa and met inclusion criteria; of these, 316 had at least one hospitalization for neutropenia. The 316 patients had 418 stays. Patients with advanced stage (vs limited stage), previous anemia (vs no anemia), positive Charlson comorbidity score (vs score of 0), and diffuse large cell histology (vs follicular) had higher mean neutropenia-related hospitalization cost/patient with non-Hodgkin's lymphoma (p<0.05). Among those with neutropenia-related hospitalizations, a longer length of stay was associated with nonfollicular histologies, previous anemia, and positive Charlson score (p<0.05). CONCLUSION: When estimating expected payments for neutropenia-related hospitalization in patients with non-Hodgkin's lymphoma, payers need to be aware of the distribution of clinical characteristics in these patients.

Adult↗
PubMed2004

The concurrent use of anticholinergics and cholinesterase inhibitors: rare event or common practice?

OBJECTIVES: To measure the prevalence of anticholinergic use cross-sectionally in patients receiving cholinesterase inhibitors and to describe change in use of anticholinergics upon inception of cholinesterase inhibitor treatment. DESIGN: Cross-sectional and inception cohort studies. SETTING: State of Iowa. PARTICIPANTS: Iowa Medicaid beneficiaries aged 50 and older with a pharmacy claim for a cholinesterase inhibitor during January 1997 through February 2000. MEASUREMENTS: Anticholinergic use was determined for all patients with a cholinesterase inhibitor pharmacy claim during January and February of 2000. A frequency distribution of all anticholinergics was compiled, with emphasis placed on those considered inappropriate in the elderly. In a separate analysis, anticholinergic use was determined at two points: 90 days before and after cholinesterase inhibitor inception. RESULTS: Of 557 patients receiving a cholinesterase inhibitor, 197 (35.4%) received an anticholinergic concurrently. Of all anticholinergics, 74.5% (178/239) had been identified as inappropriate for use in the elderly, 22.2% (53/239) under any circumstances. At the time of cholinesterase inhibitor inception, 30.2% (143/474) and 33.5% (159/474) of patients received an anticholinergic 90 days before and 90 days after inception, respectively. Increases in anticholinergic prescribing upon cholinesterase inhibitor inception exceeded decreases (Wilcoxon signed-rank test, S=529, P=.020). CONCLUSION: The concurrent use of anticholinergics and cholinesterase inhibitors is common although rarely appropriate. Patients with Alzheimer's disease deserve to receive the optimum benefit from cholinesterase inhibitor treatment, which can only be achieved through diligent and appropriate use of concurrent pharmacotherapy.

Aged↗
PubMed2003

Development of a computer algorithm for defining an active drug list using an automated pharmacy database.

BACKGROUND AND OBJECTIVE: Increasingly, pharmacy databases are being used to assist in evaluating the appropriateness of drug therapy. Such determinations often require the creation of a drug regimen at a particular point in time. The objective of this study was to develop a computer algorithm for defining a cross-sectional active drug list. METHODS: Electronic pharmacy data were obtained as part of the Iowa Medicaid Pharmaceutical Case Management Program. The active drug lists generated by the computer algorithm were compared with active drug lists generated by independent pharmacist review of the pharmacy refill data. RESULTS: In a sample of 25 patients who received 379 potentially active medications, the interrater reliability between pharmacist reviewers was excellent (kappa=0.94). In a second sample of 100 patients who received 1476 potentially active medications, the computer algorithm had a sensitivity of 93.8% and specificity of 91.7%, using pharmacist review as the comparison standard. CONCLUSION: The computer algorithm was found to be a valid method of processing electronic pharmacy data to yield a characterization of drug exposure at a point in time. The potential benefits and limitations of using this approach are discussed.

Adult↗
PubMed2003

Was breast conserving surgery underutilized for early stage breast cancer? Instrumental variables evidence for stage II patients from Iowa.

OBJECTIVE: To estimate the average survival effects of breast conserving surgery plus irradiation relative to mastectomy for marginal stage II breast cancer patients in Iowa from 1989-1994. DATA SOURCES/DATA SETTING: Secondary linked Iowa SEER Cancer Registry--Iowa Hospital Association discharge abstract data for women in Iowa with stage II breast cancer from 1989-1994. STUDY DESIGN: Observational instrumental variables (IV) analysis. DATA COLLECTION/EXTRACTION METHODS: Women with stage II breast cancer from the Iowa SEER Cancer Registry 1989-1994 who received all of their inpatient care in Iowa were linked with their respective hospital discharge abstracts. PRINCIPAL FINDINGS: Breast conserving surgery plus irradiation decreased survival relative to mastectomy for marginal stage II breast cancer patients in Iowa during the early 1990s. In this study marginal patients were those whose surgery choices were affected by differences in area treatment rates and access to radiation facilities. CONCLUSIONS: If marginal patients are representative of patients whose treatment choices would be affected by changes in treatment rates, an increase in the breast conserving surgery plus irradiation rate for stage II early stage breast cancer patients would have decreased survival in Iowa during the early 1990s. Further research with newer data and broader samples is needed to make more current and specific assessments.

Aged↗
PubMed2002

Linking clinical variables to health-related quality of life in Parkinson's disease.

OBJECTIVE: Identify the point-in-time relationship between Parkinson's disease (PD) signs and symptoms and measures of health-related quality of life (HRQL). BACKGROUND: Clinical measures used in PD assessments traditionally emphasize physical signs and symptoms. We hypothesized that these measures would be strongly associated with the physical function dimensions of HRQL that reflect mental symptoms. DESIGN/METHODS: A cross-sectional study of 193 neurology clinic PD patients employed self-administered in-clinic and take-home questionnaires and in-person clinical examinations and interviews. RESULTS: The variance explained by PD physical signs and symptoms was substantial for physical function, but only modest for all other HRQL dimensions. Mental symptoms explained a larger proportion of variance than physical symptoms for 12 of the 14 HRQL measures. CONCLUSION: PD patients' well-being, general health perceptions, health satisfaction and overall HRQL are strongly influenced by mental health symptoms and more weakly influenced by physical symptoms. Clinical evaluation of PD patients should include mental health and self-reported HRQL assessment.

Aged↗
PubMedDate not supplied

The effect of physician characteristics and their practice environment on surgical referral patterns for early-stage breast cancer in Iowa.

The objective of this article was to examine whether characteristics of referring physicians and their practice environment were associated with surgical referral behavior for early-stage breast cancer patients. A total of 2801 women diagnosed with early-stage breast cancer and their referring physicians were identified from the Iowa Surveillance, Epidemiology, and End Results (SEER) database during 1989-1996. The Iowa Physician Inventory was used to collect information on characteristics of referring physicians. Multiple logistic regression analyses were conducted to evaluate characteristics of the referring physicians and their practice environment to explain surgical referral behavior. Affiliation with physicians' networks and professional diversity among area specialists were associated with increased referrals to surgeons more likely to perform breast-conserving surgery. Promoting interaction among physicians, particularly among those with different specialties, may increase the diffusion of new behaviors into clinical practice.

Breast Neoplasms↗
PubMedDate not supplied

Factors associated with early termination of CHOP therapy and the impact on survival among patients with chemosensitive intermediate-grade non-Hodgkin's lymphoma.

BACKGROUND: Six to eight cycles of CHOP therapy (cyclophosphamide, doxorubicin, vincristine, and prednisone) is standard for intermediate-grade non-Hodgkin's lymphoma (NHL) but is associated with toxicity that may cause premature termination of therapy. METHODS: We studied factors associated with premature termination of CHOP therapy (receiving fewer than 6 cycles) and the relationship of premature termination with survival. Subjects consisted of a population-based sample of Iowa residents with intermediate-grade NHL who were planned to receive > or = 6 or more cycles of CHOP and who were chemosensitive (ie, achieved a documented partial or complete response to CHOP). RESULTS: In a comparison with patients 18-59 years of age, the odds of premature termination of CHOP therapy was 2.6 (95% CI, 0.7-9.2) for those aged 60-74 and 6.2 (95% CI, 1.7-23.3) for those aged > or = 75. Patients with cycle 1 febrile neutropenia hospitalization (FNH) were 4.4 times (95% CI, 1.4-13.8) more likely to terminate CHOP prematurely than those without cycle 1 FNH. Among patients aged 60-74, but not those aged > or = 75, premature termination appeared to be associated with decreased 5-year survival (hazard ratio [HR] = 6.0; 95% CI, 2.4-15.2) compared with those completing CHOP therapy (HR = 2.1; 95% CI, 1.0-4.2). Findings for overall survival were similar. CONCLUSIONS: First-cycle FNH and age > or = 60 years were associated with premature termination of CHOP therapy. The association of premature termination with survival among chemosensitive patients differed by age.

Adolescent↗
PubMedDate not supplied

The role of pharmacy computer systems in preventing medication errors.

OBJECTIVE: To describe the controversies and review the evidence about computer-aided prospective drug utilization review (PDUR) systems. DATA SOURCES: MEDLINE search of the literature. STUDY SELECTION: Published studies of the effectiveness of computer-aided prescription screening. DATA SYNTHESIS: One randomized, controlled trial and four nonrandomized studies constitute the evidence base. The five studies are inconclusive with respect to whether computer-aided prescription screening causes health care providers to take action, either because of a no difference finding or because there was no comparison group. In the one randomized, controlled trial, a substantial number of actions were taken by the control group whose members did not receive alerts. No study evaluated the total effect of screening by in-store and payer (online) systems. Specific research recommendations are made to increase the evidence base. CONCLUSION: Limited and inconclusive evidence about whether these systems are effective and what system features are optimal may explain the wide variation among systems in terms of what problems are screened and may also explain clinicians' uncertainty about their value. A comprehensive national research agenda for reducing medical errors should include research on the effectiveness of computer-aided PDUR.

Computer Systems↗
PubMedDate not supplied

Evaluation of the Iowa Medicaid pharmaceutical case management program.

OBJECTIVE: To test the effect of pharmaceutical case management (PCM) on medication safety and health care utilization. DESIGN: Prospective cohort design with 9-month follow-up period (enrollment from October 1, 2000, through July 1, 2001, with follow-up through July 1, 2002). SETTING: Iowa Medicaid program. PARTICIPANTS: 2,211 noninstitutionalized, continuously eligible Iowa Medicaid patients taking four or more chronic medications including at least one agent commonly used in at least 1 of 12 specific diseases who were cared for by pharmacists in 117 pharmacies. INTERVENTIONS: Reimbursement for PCM services (initial patient assessment, written recommendations to physician, follow-up assessments and communication of progress and new problems to physician). MAIN OUTCOME MEASURES: Use of high-risk medications, Medication Appropriateness Index (MAI) score, health care utilization. RESULTS: Pharmacists in 114 pharmacies had eligible patients during at least one quarter during the study period; 28 pharmacies were classified as high intensity based on the number of PCM patients they managed. A total of 524 of the eligible patients received 1,599 PCM services; 90% of claims were filed by pharmacists, and the remainder by physicians. Nearly one half (46.1%) of medications and 92.1% of patients had at least one medication problem before PCM. By closeout, the percentage of medications with problems decreased in 8 of 10 MAI domains for those who received PCM. Compared with baseline, mean MAI score improved significantly from 9.4 to 8.3 among PCM recipients (P < .001). Percentage of PCM recipients using high-risk medications decreased significantly compared with PCM eligibles who did not receive the service. In the 28 pharmacies that adopted the new service most intensely, patients had a significant decrease in high-risk medication use, compared with patients of low-intensity pharmacies (P < .001). No difference was observed between PCM recipients and PCM eligibles who did not receive PCM in health care utilization or charges, even after including reimbursements for PCM. CONCLUSION: Medication safety problems were prevalent in this high-risk population. The PCM program improved medication safety during a 9-month follow-up period.

Adult↗
PubMedDate not supplied

Days of prophylactic filgrastim use to reduce febrile neutropenia in patients with non-Hodgkin's lymphoma treated with chemotherapy.

BACKGROUND: Filgrastim prophylaxis lessens the occurrence of febrile neutropenia in patients with non-Hodgkin.s lymphoma (NHL) treated with chemotherapy, but differences in days of therapy and mode (primary or secondary) of prophylaxis may affect clinical outcomes. OBJECTIVE: To describe the patterns of use of filgrastim prophylaxis, especially days of therapy and mode, and the possible associated incidence of febrile neutropenia in patients treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. METHODS: Using medical records from the Oncology Practice Pattern Study in patients treated between 1991 and 1999 at 12 sites in the United States, we studied patients with intermediate-grade NHL treated with first-line CHOP chemotherapy and prophylactic filgrastim. The number of days of prophylactic filgrastim use, mode of prophylaxis, and incidence of febrile neutropenia were evaluated. The cycles were stratified into 2 groups based on days of filgrastim prophylaxis (<7 days [Group 1] and > or = 7 days [Group 2]). RESULTS: One hundred seventy patients were treated with 652 cycles of CHOP chemotherapy with filgrastim prophylaxis. The mean days of filgrastim prophylaxis was 9.5 days (95% confidence interval [CI], 9.3-9.7 days) across all cycles, 4.7 days (95% CI, 4.5-5.0 days) across Group 1 cycles (n=73), and 10.1 days (95% CI, 9.9-10.3 days) across Group 2 cycles (n=579). Thirty-seven percent of patients were treated with primary prophylaxis; 94% of these patients. cycles were Group 2 cycles. The incidence of febrile neutropenia was 3.6% and 7.7% across cycles in patients receiving primary versus secondary prophylaxis, respectively. In patients treated with secondary prophylaxis, the incidence was 16.7% and 6.1% in Group 1 and Group 2 cycles, respectively. Multiple logistic regression modeling indicated that a lower risk of febrile neutropenia was associated with primary prophylaxis (mainly Group 2) (odds ratio [OR] 0.3; 95% CI, 0.1-0.6) and secondary prophylaxis in Group 2 (OR 0.4; 95% CI, 0.2-0.8), and lower body surface area was associated with a greater risk of febrile neutropenia (OR 1.8; 95% CI, 1.1-3.0). CONCLUSION: Primary prophylaxis with filgrastim (mainly Group 2) and secondary prophylaxis in Group 2 (mean 10.1 days) may be associated with a lower incidence of febrile neutropenia than secondary prophylaxis in Group 1.

Aged↗
PubMedDate not supplied

Cost-effectiveness of tamsulosin, doxazosin, and terazosin in the treatment of benign prostatic hyperplasia.

OBJECTIVE: To evaluate the cost-effectiveness of tamsulosin, doxazosin, or terazosin as initial treatments for moderate benign prostatic hyperplasia (BPH) over a 3-year time horizon from a health-system-payer perspective. METHODS: A decision-analytic model is used to project the course of treatment at 6-month intervals over 3 years following initiation of therapy with tamsulosin, doxazosin, or terazosin. Treatment failure is defined as failure to attain and maintain a 25% improvement in the American Urological Association (AUA) symptom score from baseline. In the model, finasteride is added for patients who fail on their initial therapy and, in the event of finasteride treatment failure, patients progress to transurethral resection of the prostate (TURP) and, if needed, a second TURP. The ranges of values for treatment failure rates and clinical event cost parameters used in the decision model are derived from the literature. Only direct medical costs related to BPH and its treatment are included. Since 2 comparators are available generically (doxazosin and terazosin) drug acquisition costs are defined by the list prices at Drugstore.com. All costs are discounted by 3% per year. Effectiveness is measured as successful medical treatment without surgery over 3 years. RESULTS: For base-case model parameters, discounted BPH-related total direct medical costs over 3 years are 4084 dollars, 4323 dollars, and 4695 dollars for generic terazosin, generic doxazosin, and tamsulosin, respectively. The model estimates a medical treatment success rate (no TURP) at 3 years of 72.3% for tamsulosin, compared with 68.2% for both terazosin and doxazosin. The incremental cost for tamsulosin versus terazosin is 610 dollars over 3 years, which yields an incremental cost-effectiveness ratio of 14,609 dollars per success. Generic doxazosin is dominated (higher cost but equal effectiveness compared with terazosin). Higher rates of twice-daily (or 2 units per day) dosing are associated with higher incremental cost-effectiveness ratios. The decision-model results also are sensitive to the estimated costs of TURP and hypotensive adverse events. CONCLUSION: As an initial medical therapy for moderate BPH, tamsulosin is more effective than generic terazosin or doxazosin, with an incremental cost of about 203 dollars per year (or about 17 dollars per month) over 3 years.

Adrenergic alpha-Antagonists↗
PubMedDate not supplied

Extent of services provided by pharmacists in the Iowa Medicaid Pharmaceutical Case Management program.

OBJECTIVE: To summarize the start-up experience with patients identified as eligible during the first four quarters of the Iowa Pharmaceutical Case Management (PCM) program and to characterize the extent of the services proved by pharmacists in the program. DESIGN: Prospective pharmaceutical care intervention project. SETTING: One hundred seventeen community pharmacies in Iowa. PATIENTS: Medicaid patients at high risk for drug-related problems based on using 4 or more nontopical medications and having 1 of 12 specific disease states. INTERVENTION: To become eligible to provide PCM services, licensed pharmacists had to undergo training and submit five care plans to the Iowa Department of Human Services. Community pharmacists were provided names of newly eligible patents each calendar quarter for 1 year. For each patient, pharmacists were asked to indicate by fax whether they had met with the patient, performed a written work-up of the patient, sent recommendations to the patient's physician, and whether the physician replied. When pharmacists were unable to provide the service, they were asked to state the reason. Both the pharmacist and the physician receive $75 for the initial assessment, with additional payments after each follow-up visit performed. MAIN OUTCOME MEASURES: An intensity score and the percentage of eligible patients for whom all steps were completed were calculated for each pharmacy. RESULTS: Fax survey results were retumed for 2,834 (96.7%) of the 2,931 patients eligible for PCM services. Pharmacists met with 943 (33.3%), worked up 763 (26.9%), sent recommendations to physicians for 500 (17.6%), and received replies from physicians for 327 (11.5%) patients. Pharmacists were unable to provide PCM services for 1,891 (66.7%) patients. The primary reasons given for this inability to provide services were patient access issues for 438 (23.2%) patients, pharmacy staffing or start-up issues for 419 (22.2%) patients, or no reason specified for 575 (30.4%) patients. A PCM intensity score was developed to represent the scope of services provided and the number of patients served. A higher intensity score indicated pharmacies that provided PCM to more patients and/or that offered higher levels of care (e.g., provided a written set of recommendations to the physician rather than simply assessing the patient without preparing or sending recommendations). Future evaluations will determine the validity of the score on the basis of patient outcomes. CONCLUSION: Some pharmacies implemented PCM services very effectively. However, 40% to 60% of the pharmacies provided little or no PCM services within 3 months of notification of patient eligibility. Future investigations will evaluate the quality of prescribing and quality of life for patients who received PCM services.

Child↗