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Biomedical subjects

Sebastian Schneeweiss

Publications and source records attributed to Sebastian Schneeweiss.

15 recordsLinked to original sources
PubMed2003

Physician gender and changes in drug prescribing after the implementation of reference pricing in British Columbia.

BACKGROUND: Gender-specific attitudes and communication styles are known to influence both the content and outcome of medical visits. Therefore, gender-specific differences in response to cost containment may also occur. OBJECTIVE: The purpose of this study was to assess the effect of physician gender on changes in prescribing patterns of angiotensin-converting enzyme (ACE) inhibitors after the implementation of reference pricing for prescription drugs in British Columbia, Canada. METHODS: Reference pricing is a cost-sharing policy by which use of high-priced medication requires out-of-pocket payment of the price difference between the cost-sharing drug and a lower-cost drug within the same class. In British Columbia, reference pricing for ACE inhibitors was introduced on January 1, 1997. Analysis was carried out on linked pharmacy and medical service claims data on 927 female and 2922 male physicians treating 47,680 Pharmacare Plan A enrollees who were aged >-65 years and were prescribed a high-priced ACE inhibitors before the implementation of reference pricing. RESULTS: Female physicians (24.1% of all physicians) were younger, treated more female patients, had patients with fewer chronic illnesses, and worked more often as general practitioners than did male physicians. The patients of female physicians were more likely to receive a written physician-requested exemption from copayment, according to a multivariate logistic regression analysis (odds ratio [OR], 1.25; 95% CI, 1.04-1.50). Data suggested that patients of female physicians were more likely to stop antihypertensive drug therapy (OR, 1.43; 95% CI, 0.96-2.13); however, this was independent of the new copayment policy. CONCLUSIONS: The results provide empirical evidence that physician gender is associated with slightly different patient management strategies regarding physician-requested exemptions after the start of a new drug cost-sharing policy. However, these differences are unlikely to have meaningful clinical or economic consequences.

Aged↗
PubMed2003

Improved comorbidity adjustment for predicting mortality in Medicare populations.

OBJECTIVE: To define and improve the performance of existing comorbidity scores in predicting mortality in Medicare enrollees. DATA SOURCES: Study participants were two Medicare populations who had complete drug coverage either through Medicaid or a statewide pharmacy assistance program: New Jersey Medicare enrollees (NNJ, = 235,881) and Pennsylvania Medicare enrollees (NPA = 230,913). STUDY DESIGN: Frequently used comorbidity scores were computed for all subjects during the baseline year (January 1, 1994, to December 31, 1994, and one year later in Pennsylvania). The study outcome was one-year mortality during the following year. Performance of scores was measured with the c-statistic derived from multivariate logistic regression models. Empirical weights were derived in the New Jersey population and the performance of scores with new weights was validated in the Pennsylvania population. PRINCIPAL FINDINGS: A score based on ICD-9-diagnoses (Romano) performed 60 percent better than one based on patterns of medication use (Chronic Disease Score, or CDS-1) (c = 0.771 vs. c = 0.703). The performance of the Romano score was further improved slightly by inclusion of the number of different prescription drugs used during the past year. Modeling the 17 conditions included in the Romano score as separate binary indicators increased its performance by 8 percent (c = 0.781). We derived elderly-specific weights for these scores in the New Jersey sample, including negative weights for the use of some drugs, for example, lipid lowering drugs. Applying these weights, the performance of Romano and CDS-1 scores improved in an independent validation sample of Pennsylvania Medicare enrollees by 8.3 percent and 43 percent compared to the scores with the original weights. When we added an indicator of nursing home residency, age, and gender, the Romano score reached a performance of c = 0.80. CONCLUSIONS: We conclude that in epidemiologic studies of the elderly, a modified diagnosis-based score using empirically derived weights provides improved adjustment for comorbidity and enhances the validity of findings.

Aged↗
PubMed2003

European healthcare policies for controlling drug expenditure.

In the last 20 years, expenditures on pharmaceuticals - as well as total health expenditures - have grown faster than the gross national product in all European countries. The aim of this paper was to review policies that European governments apply to reduce or at least slow down public expenditure on pharmaceutical products. Such policies can target the industry, the wholesalers and retailers, prescribers, and patients. The objectives of pharmaceutical policies are multidimensional and must take into account issues relating to public health, public expenditure and industrial incentives. Both price levels and consumption patterns determine the level of total drug expenditure in a particular country, and both factors vary greatly across countries. Licensing and pricing policies intend to influence the supply side. Three types of pricing policies can be recognised: product price control, reference pricing and profit control. Profit control is mainly used in the UK. Reference pricing systems were first used in Germany and The Netherlands and are being considered in other countries. Product price control is still the most common method for establishing the price of drugs. For the aim of fiscal consolidation, price-freeze and price-cut measures have been frequently used in the 1980s and 1990s. They have affected all types of schemes. For drug wholesalers and retailers, most governments have defined profit margins. The differences in price levels as well as the introduction of a Single European Pharmaceutical Market has led to the phenomenon of parallel imports among member countries of the European Union. This may be facilitated by larger and more powerful wholesalers and the vertical integration between wholesalers and retailers. To control costs, the use of generic drugs is encouraged in most countries, but only few countries allow pharmacists to substitute generic drugs for proprietary brands. Various interventions are used to reduce the patients' demand for drugs by either denying or limiting reimbursement of products and providing an incentive for patients to reduce their consumption of drugs. These interventions include defining a list either of drugs reimbursed (positive list) or one of drugs not reimbursed (negative list), and patient co-payments, which require patients to pay a proportion of the cost of a prescribed product or a fixed charge. Policies intended to affect physicians' prescribing behaviour include guidelines, information (about price and less expensive alternatives) and feedback, and the use of budgetary restrictions.

Cost Control↗
PubMed2002

Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study.

OBJECTIVE: To estimate incidence rates of drug-related hospitalizations (DRHs) in a longitudinal population-based study with prospective event assessment. DESIGN: Cohort study and time-trend analysis. SETTING: All departments of internal medicine and emergency departments in the urban regions of Jena and Rostock, Germany, serving about 520,000 residents. PARTICIPANTS: All patients admitted between October 1997 and March 2000. Patients with severe cutaneous reactions were excluded. MAIN OUTCOME MEASURES: Incidence of DRH was defined by symptoms or diagnoses at admission that were very likely, likely, or possibly caused by prescription medications, according to a standardized assessment. RESULTS: The incidence of DRH was 9.4 admissions per 10,000 treated patients [95% confidence interval (CI) 9.0-9.9]. Rates were highest for antithrombotics with 26.9 admissions per 10,000 treated patients (95% CI 23.6, 30.1). Most frequent events were gastroduodenal lesions and bleeding (45%). Digitalis preparations showed a linearly increasing trend from 2/10,000 to 14/10,000 during ten quarters ( P<0.0001), which was exclusively attributable to digitoxin, the major source of digitalis in the study area (93%). The incidence of DRH increased with age (4/10,000 to 20/10,000). The mean length of stays in patients with DRH was 13+/-10.6 days. Cumulative direct costs for hospitalization were Euro 4 million in the two urban study areas. The annual direct costs for Germany were estimated to be Euro 400 million. CONCLUSIONS: DRHs are a considerable public health and economic burden. A longitudinal design can observe changes in population-based incidence over time. This approach can be used for public-health planning or to evaluate outcomes of quality management programs designed to reduce drug-induced illness.

Adolescent↗
PubMed2002

Impact of reference-based pricing for angiotensin-converting enzyme inhibitors on drug utilization.

BACKGROUND: Increasing copayments for higher-priced prescription medications has been suggested as a means to help finance drug coverage for elderly patients, but evaluations of the impact of such policies are rare. The objective of this study was to analyze the effect of reference-based pricing of angiotensin-converting enzyme (ACE) inhibitors on drug utilization, cost savings and potential substitution with other medication classes. METHODS: We analyzed 36 months of claims data from British Columbia for 2 years before and 1 year after implementation of reference-based pricing (in January 1997). The 119,074 patients were community-living Pharmacare beneficiaries 65 years of age or older who used ACE inhibitors during the study period. The main outcomes were changes over time in use of ACE inhibitors, use of antihypertensive drugs and expenditures for antihypertensive drugs, as well as predictors of medication switching related to reference-based pricing. RESULTS: We observed a sharp decline (29%) in the use of higher-priced cost-shared ACE inhibitors immediately after implementation of the policy (p < 0.001). After a transition period, the post-implementation utilization rate for all ACE inhibitors was 11% lower than projected from pre-implementation data. However, overall utilization of antihypertensives was unchanged (p = 0.40). The policy saved $6.7 million in pharmaceutical expenditures during its first 12 months. Patients with heart failure or diabetes mellitus who were taking a cost-shared ACE inhibitor were more likely to remain on the same medication after implementation of reference-based pricing (OR 1.12 [95% confidence interval, CI, 1.06-1.19] and 1.28 [95% CI 1.20-1.36] respectively). Patients with low-income status were more likely than those with high-income status to stop all antihypertensive therapy (OR 1.65 [95% CI 1.43-1.89]), which reflects a general trend toward discontinuation of therapy among these patients even before implementation of reference-based pricing. INTERPRETATION: Reference-based pricing in British Columbia achieved a sustained reduction in drug expenditures, and no changes in overall use of antihypertensive therapy were observed. Further research is needed on the overall health and economic effects of such policies.

Aged↗
PubMed2002

Outcomes of reference pricing for angiotensin-converting-enzyme inhibitors.

BACKGROUND: In January 1997, reference pricing for angiotensin-converting-enzyme (ACE) inhibitors for patients 65 years of age or older was introduced in British Columbia, Canada. For medications within a specific class, insurance covers the cost up to the reference price, and patients pay the extra cost of more expensive medications. Although reference pricing may reduce the costs of prescription drugs, there is concern that patients may switch to less effective medications or stop treatment. METHODS: We analyzed data from the Ministry of Health on all 37,362 residents of British Columbia who were 65 or older and were enrolled in the provincial health insurance program, received ACE inhibitors priced higher than the reference price of $27 a month in 1996, and were potentially affected by the new policy. We identified 5353 residents who switched to an ACE inhibitor not subject to cost sharing during the first six months and compared them with 27,938 residents who received only ACE inhibitors subject to cost sharing. RESULTS: Reference pricing for ACE inhibitors was not associated with changes in the rates of visits to physicians, hospitalizations, admissions to long-term care facilities, or mortality. The probability of stopping antihypertensive therapy decreased as compared with the probability before the change in policy (relative risk, 0.76; 95 percent confidence interval, 0.65 to 0.89). Eighteen percent of patients who had been prescribed ACE inhibitors subject to cost sharing switched to lower-priced alternatives. As compared with patients who did not switch, those who did had a moderate transitory increase in the rates of visits to physicians (rate ratio, 1.11; 95 percent confidence interval, 1.07 to 1.15) and hospital admissions through the emergency room (rate ratio, 1.19; 95 percent confidence interval, 0.99 to 1.42) during the two months after switching, but not subsequently. CONCLUSIONS: We found little evidence that when reference pricing for ACE inhibitors was introduced in British Columbia, patients stopped treatment for hypertension or that health care utilization and costs increased.

Aged↗
PubMed2002

Measuring the cost-effectiveness of lipid-lowering drugs in the elderly: the outcomes research and economic analysis components of the PROSPER trial.

Little information exists to quantify the functional status and economic consequences of lipid-lowering therapy in elderly patients. We describe the design of the cost-effectiveness component of the first large, randomized, placebo-controlled trial of lipid-lowering therapy in subjects aged 70 years or older. The PROspective Study of Pravastatin in the Elderly at Risk has randomized 5804 men and women 70-82 years old, with existing vascular disease or related risk factors, to receive 40 mg/d of pravastatin or placebo. The cost-effectiveness study will be based on within-trial observations of differences between the two study arms in rates of myocardial infarction, stroke and related vascular disease outcomes (including vascular dementia). In addition to comparing within-trial clinical outcomes, we will model the projected changes in life expectancy and cardiovascular outcome rates that would be seen with lifelong use of the drug, based on the risk reduction rates seen in the trial as well as baseline observational data from the three countries where the trial is being conducted (Scotland, Ireland and the Netherlands). A state transition (Markov) model will be constructed to estimate the likely states of health, functional status and health care resource utilization (including lipid-lowering drug costs) in a cohort of elderly patients with versus without pravastatin therapy over a series of 1-year cycles until death. In addition, a standard measure of utility (the Health Utilities Index) will be administered to all study subjects to permit calculation of quality-adjusted life-years gained with this regimen. This approach will make it possible to go beyond the calculation of a single endpoint for each subject, and to translate the trial findings into definitions of effectiveness and outcomes that will be relevant to the ongoing debate concerning how best to relate the benefits of such medications to their costs.

Aged↗
PubMed2002

Quasi-experimental longitudinal designs to evaluate drug benefit policy changes with low policy compliance.

A causal relation between drug benefit policy change and the increase in adverse outcomes can be tested by comparing the experience of a group of patients affected by the policy vs. the (counterfactual) experience of the same patients if the policy had not been implemented. Because counterfactual experiences cannot be observed, it must be assumed that the counterfactual is correctly described by extrapolating from the same population's previous experience. The null hypothesis of no policy effect can be empirically tested using quasi-experimental longitudinal designs with repeated measures. If compliance to a policy is low, results may be biased towards the null, but a subgroup analysis of compliers may be biased by nonignorable treatment selection. Using the example of reference drug pricing in British Columbia we discuss assumptions for causal interpretations of such analyses, and provide supplementary analyses to assess and improve the validity of findings. Results from nonrandomized comparisons of subgroups defined by their compliance to a policy change should generally be interpreted cautiously, and several biases should be explored.

Attitude of Health Personnel↗
PubMed2002

Prescription duration after drug copay changes in older people: methodological aspects.

OBJECTIVES: Impact assessment of drug benefits policies is a growing field of research that is increasingly relevant to health care planning for older people. Some cost-containment policies are thought to increase noncompliance. This paper examines mechanisms that can produce spurious reductions in drug utilization measures after drug policy changes when relying on pharmacy dispensing data. Reference pricing, a copayment for expensive medications above a fixed limit, for angiotensin-converting enzyme(ACE) inhibitors in older British Columbia residents, is used as a case example. DESIGN: Time series of 36 months of individual claims data. Longitudinal data analysis, adjusting for autoregressive data. SETTING: Pharmacare, the drug benefits program covering all patients aged 65 and older in the province of British Columbia, Canada. PARTICIPANTS: All noninstitutionalized Pharmacare beneficiaries aged 65 and older who used ACE inhibitors between 1995 and 1997 (N = 119,074). INTERVENTION: The introduction of reference drug pricing for ACE inhibitors for patients aged 65 and older. MEASUREMENTS: Timing and quantity of drug use from a claims database. RESULTS: We observed a transitional sharp decline of 110% t a standard error of 30% (P = .02) in the overall utilization rate of all ACE inhibitors after the policy implementation; five months later, utilization rates had increased, but remained under the predicted prepolicy trend. Coinciding with the sharp decrease, we observed a reduction in prescription duration by 31% in patients switching to no-cost drugs. This reduction may be attributed to increased monitoring for intolerance or treatment failure in switchers, which in turn led to a spurious reduction in total drug utilization. We ruled out the extension of medication use over the prescribed duration through reduced daily doses (prescription stretching) by a quantity-adjusted analysis of prescription duration. CONCLUSION: The analysis of prescription duration after drug policy interventions may provide alternative explanations to apparent short-term reductions in drug utilization and adds important insights to time trend analyses of drug utilization data in the evaluation of drug benefit policy changes.

Age Factors↗
PubMed2002

Metric properties of the appropriateness evaluation protocol and predictors of inappropriate hospital use in Germany: an approach using longitudinal patient data.

BACKGROUND: The German health care system, renowned for its unrestricted access, high quality care, and comprehensive coverage, is challenged by increasing health care costs. This has been attributed partly to inefficiencies in the in-patient sector, but has been studied little. Attempts at quality improvement need to relate costs to outcomes. Until now, there has been no standardized methodology to evaluate the appropriateness of hospital care. OBJECTIVE: To develop and evaluate the metric properties of a method to assess inappropriate hospital care in Germany based on a widely used measure, the Appropriateness Evaluation Protocol (AEP). METHODS: The original AEP was translated and adapted to reflect differences in the provision of health care in Germany. Psychometric testing was performed in a stratified sample of all patients admitted to the Departments of Medicine and Surgery of a 400-bed teaching hospital during 1 year. Three board-certified physicians participated in each department to evaluate intra-rater reliability, while two additional independent physicians judged inter-rater reliability. RESULTS: Inter-rater agreement for the evaluation of hospital days among surgical patients was 84% (80-87%), with an average kappa value of 0.58 (0.48-0.68). Corresponding figures for patients in medicine were 76% (73-80%) with a K value of 0.42 (0.34-0.42). Inter-rater agreement for hospital admissions and K was 74% (62-86%) and 0.44 (0.21-0.67) in surgery, and 92% (85-100%) and 0.31 (0-0.80) in medicine, respectively. Thirty-three per cent of all admissions and 28% of consecutive hospital days were judged inappropriate in surgery; among medicine patients, reviewers found 6% of admissions and 33% of hospital days inappropriate. Time since admission was the strongest predictor of inappropriate hospital use adjusted for length of stay, comorbidity, age, and gender.

Adult↗
PubMed2002

Clozapine use and risk of diabetes mellitus.

Recent reports have raised the concern that clozapine increases the risk for diabetes mellitus. Accurate pharmacoepidemiologic data on whether such a hazard exists and its magnitude are needed to enable clinicians and patients to make proper treatment decisions about clozapine. The authors performed a case-control study involving 7,227 cases of newly treated diabetes and 6,780 controls, all with psychiatric disorders. Cases and controls were older than 20 years and enrolled in government-sponsored drug benefit programs in New Jersey. The authors measured the use of clozapine or other antipsychotic medications and additional covariates. They developed logistic regression models adjusted for demographic, clinical, and health care use characteristics to identify whether clozapine users were at increased risk to begin treatment for diabetes. Clozapine use was not significantly associated with developing diabetes (adjusted odds ratio [OR], 0.98; 95% confidence interval [CI], 0.74-1.31). There was no suggestion of relationships between larger dosages or longer durations of clozapine use and increasing risks of diabetes. On the other hand, nonclozapine antipsychotic medication use was associated with a modest but significantly increased risk of developing diabetes (adjusted OR, 1.13; 95% CI, 1.05-1.22). Among individual nonclozapine antipsychotics, significantly elevated risks were observed for two phenothiazine agents: chlorpromazine (adjusted OR, 1.31; 95% CI, 1.09-1.56) and perphenazine (adjusted OR, 1.34; 95% CI, 1.11- 1.62). In contrast to earlier reports, these results provide some reassurance that clozapine does not increase the risk of developing diabetes. Additional data from pharmacoepidemiologic studies and randomized controlled trials are needed to exclude the possibility of residual confounding and ensure the appropriate use of this agent.

Adult↗
PubMed2002

[Outcomes count: the importance of measuring the outcomes of hospital care].

A century ago the Boston surgeon Earnest A. Codman described in detail the requirements for monitoring quality of care and emphasized the importance of outcomes in evaluating care. At the time the medical societies were disconcerted by his ideas, which were perceived as revolutionary. After several decade of focusing on the structures and processes of care we are now witnessing a renaissance of measuring outcomes. This paper emphasizes the need for outcomes measurement monitor quality of care. The introduction of diagnosis-related groups in Germany is the most recent development that underlines the importance of outcomes measurement and benchmarking.

Germany↗
PubMedDate not supplied

Costs of measuring outcomes of acute hospital care in a longitudinal outcomes measurement system.

It is widely acknowledged that the measurement of outcomes of care and the comparison of outcomes over time within health care providers and risk-adjusted comparisons among providers are important parts of improving quality and cost-effectiveness of care. However, few studies have assessed the costs of measuring outcomes of care. We sought to evaluate the personnel and financial resources spent for a prospective assessment of outcomes of acute hospital care by health professionals in internal medicine. The study included 15 primary care hospitals participating in a longitudinal outcomes measurement program and 2005 patients over an assessment period with an average duration of 6 months. Each hospital project manager participated in a previously-tested structured 30-minute telephone interview. Outcome measures include time spent by the individual job titles in implementing and running the outcomes measurement program. Job-title-specific times were used to calculate costs from the hospitals' perspective. One-time costs (2132 +/- 1352 Euros) and administrative costs (95 +/- 97 Euros per week) varied substantially. Costs per patient were fairly stable at around 20 Euros. We estimated that the total cost for each hospital to assess outcomes of care for accreditation (10 tracer diagnoses over 6 months) would be 9700 Euros and that continuous monitoring of outcomes (5 tracer diagnoses) would cost 12,400 Euros per year. This study suggests that outcomes of acute hospital care can be assessed with limited resources and that standardized training programs would reduce variability in overall costs. This study should help hospital decision makers to estimate the necessary funding for outcomes measurement initiatives.

Hospital Costs↗