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Biomedical subjects

John M Inadomi

Publications and source records attributed to John M Inadomi.

At least 19 recordsLinked to original sources
PubMed2007

On-demand therapy for gastroesophageal reflux disease.

The following pages summarize the proceedings of a symposium held in May 2006 on the emerging role of on-demand therapy for gastroesophageal reflux disease (GERD). Medical therapy for GERD has undergone significant change in recent years with the advent of effective, but expensive, antisecretory agents. On-demand (patient-driven) therapy is attractive to payers and patients, because it appears to be both cost-effective and convenient. Many individuals appear to accept occasional symptomatic breakthrough in exchange for personal control of their disease. On-demand therapy should be distinguished from intermittent therapy, which is either patient- or physician-driven, but which requires intermittent episodes of continuous therapy followed by discontinuation until symptoms recur. Proton pump inhibitors appear to be effective on-demand agents despite theoretical pharmacodynamic limitations for this class of drug. The available data support the use of on-demand therapy for GERD in uninvestigated reflux disease, nonerosive reflux disease, and possibly mild esophagitis as well. On-demand therapy should not be considered for patients with severe esophagitis.

Congresses as Topic↗
PubMed2006

Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients.

BACKGROUND: Although administration of stress ulcer prophylaxis (SUP) has been recommended for specific patients in the intensive care unit (ICU) setting, this practice has been extrapolated to care of non-ICU patients without evidence to support need or efficacy. AIMS: To examine the practice of SUP in non-ICU patients in a university hospital setting, with specific attention to resource utilization. METHODS: Retrospective chart review of adult non-ICU admissions to one family medicine and five general internal medicine teaching services over a consecutive 4-month period. Proportion of patients prescribed SUP was ascertained after exclusion of patients admitted on antisecretory therapy (AST) or prescribed AST for non-SUP indications. Annual cost estimates were calculated assuming full compliance. RESULTS: Of 1,769 patient admissions, 22% received SUP and 54% of these were discharged home on AST. None of these patients met evidence-based criteria for appropriate SUP. Inpatient SUP cost Dollars 11,024 over the 4 months of the study (Dollars 44,096 annually), and outpatient costs based on discharge prescriptions were Dollars 16,924 (Dollars 67,695 annually), yielding a total cost expenditure of Dollars 27,948 (Dollars 111,791 annually). CONCLUSION: SUP is overutilized in the non-ICU setting, and patients are often discharged unnecessarily on AST, resulting in significant cost expenditure. Interventions to ensure appropriate use of SUP should decrease resource expenditures without detrimental impact on quality of care.

Adult↗
PubMed2006

Defining a clinically significant adverse impact of diagnosing Barrett's esophagus.

BACKGROUND: Diagnosing a potentially life-threatening disease may adversely affect patient quality of life (QOL) independent of biologic effects. It is unknown whether the mere diagnosis of Barrett's esophagus (BE) adversely impacts patients' preferences (health-state utility) sufficiently to impair the cost-effectiveness of endoscopic screening for esophageal adenocarcinoma. GOAL: To calculate the threshold impact on utility incurred by diagnosing BE that would allow screening to remain cost-effective. STUDY: A Markov model was developed to examine strategies of no screening, and screening with surveillance of BE. Patients were 50-year-old white men with symptoms of gastroesophageal reflux followed until 80 years of age or death. The primary outcomes were the threshold decrements in utility incurred by diagnosing BE based on willingness to pay (WTP) of dollar 50,000 and dollar 100,000 per quality-adjusted life-year (QALY) gained. RESULTS: For a WTP of dollar 50,000/QALY, the decrement in utility could be as great as 9%, meaning that screening is cost-effective as long as diagnosing BE does not impair QOL by more than 9%. For a WTP of dollar 100,000, the decrement could be as great as 10.5%. CONCLUSIONS: The decrement in utility caused by diagnosing BE may be substantial without compromising the cost-effectiveness of endoscopic screening.

Adenocarcinoma↗
PubMed2005

Women patients' preference for women physicians is a barrier to colon cancer screening.

BACKGROUND: The preference of women patients for women physicians has been shown in many specialties. Women patients awaiting a lower endoscopy have been shown to have a preference for women endoscopists. The reasons for this preference and the strength of this preference have not been studied in the primary care setting. METHODS: A questionnaire was given to female patients who were waiting for primary care appointments at 4 offices. Patients reported sociodemographic characteristics, experiences with colorectal cancer (CRC), barriers to CRC screening, gender preference of their physician, the significance, and reasons for this preference. RESULTS: A total of 202 women patients aged 40 to 70 years (mean 53 years) completed the questionnaire. Of these patients, 43% preferred a woman endoscopist, and of these, 87% would be willing to wait >30 days for a woman endoscopist, and 14% would be willing to pay more for one. The most common reason (in 75%) for this gender preference was embarrassment. Univariate analysis revealed that gender of the primary care physician (PCP), younger patient age, current employment, and no previous history of colonoscopy were predictors of preference for a woman endoscopist. Of these variables, only female gender of the PCP (OR 2.84: 95% CI[1.49, 5.40]) and employment (OR 2.4: 95% CI[1.23, 4.67]) were positive predictors for a woman endoscopist preference by multivariable analysis; 5% stated that they would not undergo a colonoscopy unless guaranteed a woman endoscopist. The sole independent factor associated with adherence to screening was PCP recommendation (OR 2.93: 95% CI[1.63, 5.39]). CONCLUSIONS: Women patients frequently prefer a woman endoscopist, and this preference is reported as being strong enough to delay the procedure and to incur personal expense. It is an absolute barrier to endoscopy according to 5% in this subset of women surveyed. Interventions must be made in the primary care setting to address this issue and to increase the participation of women patients in CRC screening.

Adult↗
PubMed2005

PPI use in the OTC era: who to treat, with what, and for how long?

Proton pump inhibitors (PPIs) have been shown to be the most effective class of medication to treat gastroesophageal reflux disease (GERD). The availability of over-the-counter (OTC) and generic PPIs provides consumers with options other than antacids and histamine 2 -receptor antagonists (H2RAs) for self-medication of heartburn and acid regurgitation. Medical concerns arising from these developments include management of patients in whom symptoms persist despite OTC PPI, proper administration of PPIs, and potential masking of more serious pathology, such as malignancy. Current studies indicate that it is likely that different forms of PPI administration will become more acceptable, such as on-demand and intermittent therapy. Prospective clinical trials show the efficacy of these strategies of noncontinuous PPI administration, and the potential for cost reduction in GERD management. Newer agents such as reversible acid pump antagonists will compete for selected markets in the future, further expanding the role of alternative dosing regimens. Ultimately, therapy should be tailored to individual patients because no single strategy will be optimal for the entire population with GERD symptoms.

Antacids↗
PubMed2005

Primary-care physicians' perceptions and practices on the management of GERD: results of a national survey.

BACKGROUND: Gastroesophageal reflux disease (GERD) is frequently managed by primary-care physicians (PCPs) although little is known about their current practices and management patterns. METHODS: We administered a questionnaire-based survey to PCPs attending sponsored educational conferences on GERD. Questionnaires were completed anonymously before the conferences and asked about prescribing patterns, indications for surgical referral, and issues concerning Barrett's esophagus and H. pylori infection. RESULTS: A total of 1046 completed questionnaires (97% acceptance rate) were received. Most PCPs prescribed a proton pump inhibitor (PPI) for GERD without prior authorization and without first using an H2-receptor antagonist (H2RA). Many gave an H2RA with once-daily PPI treatment for patients with nocturnal heartburn. Most referrals for anti-reflux surgery were for inadequate response to medical treatment, although PCPs usually first sought gastroenterological consultation. There was a widespread acceptance of screening GERD patients for Barrett's esophagus. There was general confusion about any relationship between H. pylori infection and GERD; 80% of PCPs tested for the infection in at least some patients who only had symptoms of GERD. CONCLUSIONS: Our survey has identified a number of areas of controversy and confusion related to the management of GERD. We hope that our findings can assist in the development of educational materials on GERD for PCPs.

Anti-Ulcer Agents↗
PubMed2004

Decision analysis and economic modelling: a primer.

In this primer, the reader is introduced to the concepts governing decision analysis and cost-effectiveness analysis. The construction of decision trees and Markov models is presented to provide the necessary background to critique research articles in published literature. Specific sub-topics related to cost-effectiveness analysis are discussed including quality adjustment and utilities (patient preferences for health states), discounting, and sensitivity analysis including Monte Carlo simulation. Evidence based methods to critique decision and cost-effectiveness analysis are provided, and limitations to these analytic methods are examined. In summary, the major functions of decision analysis and cost-effectiveness analysis are to provide: (1) a quantitative summary of existing data, and (2) hypothesis generation for further research.

Cost-Benefit Analysis↗
PubMed2004

A cost-utility analysis of secondary prophylaxis for variceal hemorrhage.

BACKGROUND: Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation. OBJECTIVE: The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies. METHODS: A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence. DATA SOURCES: Published literature and the Health Care Financing Administration. TARGET POPULATION: People with cirrhosis and a history of controlled VH. TIME HORIZON: Three years. PERSPECTIVE: Third-party payer. OUTCOME MEASURES: Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained. RESULTS OF BASE-CASE ANALYSIS: Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs. RESULTS OF SENSITIVITY ANALYSIS: Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases. CONCLUSIONS: TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.

Adolescent↗
PubMed2003

Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis.

BACKGROUND: Once-in-a-lifetime screening for Barrett esophagus has been proposed for patients with gastroesophageal reflux disease (GERD), but there is little evidence of its cost-effectiveness. OBJECTIVE: 1) To determine the cost-effectiveness of screening high-risk groups for Barrett esophagus and providing surveillance to patients with Barrett esophagus and dysplasia or to all patients with Barrett esophagus and 2) to compare the results with the cost-effectiveness of no screening or surveillance. DESIGN: A decision analytic model was developed to examine no screening or surveillance and screening and surveillance for Barrett esophagus with dysplasia only or Barrett esophagus without dysplasia every 2 to 5 years. Low- or high-grade dysplasia received surveillance every 6 or 3 months, respectively. DATA SOURCES: Published literature and the Health Care Financing Administration. TARGET POPULATION: 50-year-old white men with symptoms of GERD. TIME HORIZON: 50 years of age until 80 years of age or death. PERSPECTIVE: Third-party payer. OUTCOME MEASURE: Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS: Screening with surveillance limited to patients with Barrett esophagus with dysplasia required $10 440 per quality-adjusted life-year (QALY) saved compared to no screening or surveillance. The incremental cost-effectiveness ratio of surveillance every 5 years in patients with Barrett esophagus without dysplasia compared to surveillance of patients with Barrett esophagus with dysplasia was $596 000 per QALY saved. RESULTS OF SENSITIVITY ANALYSIS: The annual incidence of adenocarcinoma must exceed 1 case per 54 patient-years of follow-up (1.9%) for surveillance of Barrett esophagus without dysplasia every 5 years to yield an incremental cost-effectiveness ratio less than $50 000 per QALY saved. CONCLUSIONS: Screening 50-year-old men with symptoms of GERD to detect adenocarcinoma associated with Barrett esophagus is probably cost-effective. However, subsequent surveillance of patients with Barrett esophagus but no dysplasia, even at 5-year intervals, is an expensive practice.

Adenocarcinoma↗
PubMed2003

An evidence-based medicine approach to economic studies: assessing the cost-effectiveness of competing strategies for colorectal cancer screening.

Cost-effectiveness analysis aims to quantitatively compare the expected outcomes of competing management strategies in environments with limited economic resources. A valid economic study models all relevant strategies from an appropriate perspective. The model must use costs that are accurately measured and strategies that have established clinical effectiveness, and appropriately integrate these data. The results should include the incremental cost-effectiveness ratio, which quantifies the resources required to achieve greater benefit with one strategy compared to another. A sensitivity analysis is required to determine whether uncertainty in assumptions alters the conclusions. Final interpretation of a cost-effectiveness analysis relies on whether costs and outcomes in the study can be realized in one's own health care environment.

Colorectal Neoplasms↗
PubMed2003

Update on the cost-effectiveness of screening for colorectal neoplasia.

Colorectal cancer is an ideal target for population screening because it is a prevalent disease with an identifiable precursor lesion that, when treated, favorably alters the natural history of the disease. Several strategies for screening have illustrated efficacy, including fecal occult blood testing, sigmoidoscopy and colonoscopy. Cost-effectiveness analyses have been performed to determine whether the resources required to implement screening are justified by potential gains. The U.S. Preventive Services Task Force recently commissioned a study on the cost-effectiveness of colorectal cancer screening, which revealed that screening was cost-effective compared to no screening. However, it could not be confirmed which strategy would save the most life-years, nor which was most cost-effective. Since publication of this review, several additional cost-effectiveness analyses have been performed. These studies confirm that screening average risk patients at age 50 by a variety of available strategies is likely to be reasonable by current standards for resource utilization, and that either colonoscopy every 10 years (or once at age 65) or the combination of annual fecal occult blood testing with sigmoidoscopy every 5 years are viable alternatives. Additional economic analyses have examined the use of aspirin chemoprophylaxis to prevent colorectal cancer either alone or as an adjunct to screening strategies. These studies reaffirm the cost-effectiveness of colorectal cancer screening, but illustrate that aspirin chemoprophylaxis is unlikely to be associated with gains for which society would be willing to pay. At present, the decision to choose one colorectal screening strategy over another is based on availability of screening modalities, patient and provider preferences, and associated adherence to screening recommendations. Assessment of preference and development of interventions to increase adherence to screening should be a focus of research in the future.

Journal Article↗
PubMed2003

Step-down from multiple- to single-dose proton pump inhibitors (PPIs): a prospective study of patients with heartburn or acid regurgitation completely relieved with PPIs.

OBJECTIVES: Management costs for gastroesophageal reflux disease are high because of the expensive medications used for maintenance therapy. Previous studies have illustrated the success of step-down from proton pump inhibitors (PPIs) to less-expensive therapy once symptoms have abated. This study was conducted to determine whether patients requiring greater than single-dose PPI for initial symptom resolution could be stepped-down to single-dose PPI and whether this intervention decreased costs or adversely affected quality of life. METHODS: Consecutive patients in whom greater than single-dose PPI had completely alleviated reflux-type symptoms (heartburn or acid regurgitation) were recruited through the use of pharmacy records of PPI prescriptions. Eligible subjects completed baseline demographic information and quality-of-life surveys and were stepped-down to single-dose PPI (lansoprazole 30 mg or omeprazole 20 mg daily). Follow-up continued for 6 months or until subjects reported recurrence of reflux-type symptoms, at which point PPIs were reinstituted at the dose that had originally alleviated the subjects' symptoms. The primary outcome was the proportion of subjects in whom step-down was successful, defined as no recurrence of reflux-type symptoms on single-dose PPI. RESULTS: A total of 117 subjects enrolled in the study; all were followed to the primary endpoint. 79.5% did not report recurrent symptoms of heartburn or acid regurgitation during the 6 months after step-down to single-dose PPI. Logistic regression revealed that longer duration of PPI use before study enrollment was associated with greater likelihood of symptom recurrence with step-down. Although quality of life was not significantly altered, dyspepsia (excluding reflux-type symptoms) increased. Overall costs of management were reduced. CONCLUSIONS: The majority of patients rendered asymptomatic on greater than single-dose PPI might be subsequently stepped-down to single-dose therapy without recurrence of reflux-type symptoms. This intervention can decrease management costs without adversely affecting quality of life.

2-Pyridinylmethylsulfinylbenzimidazoles↗