Costs, outcomes and estimation of the cost-effectiveness of abciximab in the prevention of ischemic events over six months of follow-up
Abstract
Abciximab is an antiplatelet inhibitor used in conjunction with percutaneous revascularization procedures to decrease the risk of ischemic complications such as death, nonfatal MI or subsequent revascularization procedures like angioplasty or CABG. Although the efficacy of abciximab is rarely disputed based on evidence from three large clinical trials, the cost-effectiveness of the drug when used during routine practice has been questioned since it costs approximately $1,350 per patient treated. This study was undertaken to estimate the effectiveness of abciximab in patients treated at University of Maryland Medical System (UMMS) and to estimate the incremental cost-effectiveness ratio (ICER) defined as the cost per event avoided. The composite endpoint consisted of death, MI or subsequent revascularization procedure over 6-months of follow-up. Proportional hazards regression revealed that abciximab was associated with a lower risk of ischemic events among patients with more severe angiographic morphology. Patients who received a shortened infusion of the drug (<10 hours) were at a greater risk of experiencing an event than those who received an infusion for 10-14 hours. Also, patients who underwent coronary stenting were less likely to have an event while patients with multivessel disease or a history of a percutaneous revascularization procedure were at a higher risk of experiencing an event. The cost-effectiveness analysis was performed for a subgroup of patients with more severe coronary morphology using a matched cohort design. The point estimate of the ICER revealed that it cost about $20,680 to prevent an ischemic event over six months in high-risk patients treated with abciximab. Confidence intervals for the ICER were computed using Taylor series approximation, Fieller's theorem and bootstrapping, and were graphically represented with ellipses of equal probability. Overall, the data were consistent with a wide range of plausible estimates due to a relatively small denominator in the ICER.Description
University of Maryland, Baltimore. Pharmacy Administration. Ph.D. 1998Keyword
Health Sciences, Medicine and SurgeryHealth Sciences, Pharmacy
Health Sciences, Public Health
Health Sciences, Health Care Management
abciximab
Cost-Benefit Analysis
Platelet Aggregation Inhibitors--economics
Platelet Aggregation Inhibitors--therapeutic use
Identifier to cite or link to this item
http://hdl.handle.net/10713/1351Related items
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The impact of the state of Maryland's Medicaid mental health carve-out on access-to-care for patients in a suburban health care systemIn recent years, providing care for individuals with severe mental illness has consumed increasing state and federal financial resources, with State Medicaid systems bearing the heaviest burden. Managed care strategies have been initiated by public mental health systems as a mechanism to control expenses. The state of Maryland implemented a mental health carve-out on July 1, 1997. The purpose of the present study is to describe the effects of the carve-out on access-to-care for individuals using emergency department services in one suburban health care system. Data for this study included all episodes of emergency crisis care in pre-implementation (1996-1997) and post-implementation (1998-1999) time periods. These data were examined within the context of the Behavioral Model of Health Service Use (Andersen, 1995) to describe the interrelationships among external environment, predisposing characteristics, and enabling resources on use of health services. Use of health services was operationalized by four outcomes: disposition, length of stay, number of visits, and recidivism. There were a total of 2986 episodes, initiated by 1928 individuals. Logistic regression demonstrated that when controlling for predisposing characteristics and enabling resources, the likelihood of inpatient admission did not change after initiation of the program. Moreover, there was not a significant change in the number of emergency visits. The assessment of recidivism demonstrated that only psychotic disorders (a predisposing characteristic) were a significant predictor of 30-day repeat visits. Multiple regression models examining the impact of the carve-out on length of stay demonstrated a significant increase in the emergency department length of stay (F = 5.47, p = .05) following the implementation of the carve-out. While benefits associated with improved coordination of services might be expected with the implementation of the carve-out, there was not a change in inpatient admissions, number of emergency visits, or recidivism. Additionally, there was a significant increase in the amount of time required to assess patients and to provide an appropriate disposition. The limited study sample and data prohibit generalizability. Considering that evaluations of mental health carve-outs are limited, this study reflects that anticipated benefits have not been experienced in emergency departments.
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Development of a measure of the content and quality of prenatal care services in a Medicaid populationStatement of the problem. The purpose of this study was to develop an instrument to measure the content and quality of prenatal care services in a population of low income women. Dimensions of performance as proposed by the Joint Commission on Accreditation of Healthcare Organizations were used to define the quality of prenatal care. The United States Public Health Service Expert Panel Guidelines on the Content of Prenatal Care were used as the standard for the content of care. Methods. The Content and Quality of Prenatal Care Measure (CQPM), a prenatal care record review measure, was developed in this study. An assessment of content validity and intra- and inter-rater reliability was completed. Data collected for the validity sample of 163 records at two county health department sites was scored by content area. The Adequacy of Prenatal Care Utilization Index (APNCU) developed by Kotelchuck was used to categorize each record in the validity sample. Criterion-related validity was assessed with ANOVA using the CQPM scores as the dependent variable and the APNCU groups as the independent variable and by discriminant function analysis using the CQPM content scores as predictors for group membership in APNCU groups. Results. The mean percent agreement for each of the content areas for intra- and inter-rater reliability ranged from 72% to 95% with medical risk assessment having the highest reliability and health promotion having the lowest. Intra and inter-rater percent agreement for items ranking the quality of care was 70% and 51.6%. A significant difference between the groups was found in ANOVA, F(3,157):16.23, p < .00001, confirming criterion-related validity. The discriminant function analysis found an overall Lambda =.451941 (chi2 = 110.79, df 15, p < .00001). The prediction equation accounted for 62% of grouped cases being correctly classified also confirming criterion-related validity. Discussion. These results show that the Content and Quality of Prenatal Care Measure is reliable and valid and may be used to monitor care provided to low income populations and to conduct research on the content of prenatal care. Further research on weighting each item score in the CQPM and the reliability of items for special populations may be indicated.
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Nurses' work environment and job satisfactionBackground. Transforming nurses' work environment has become a concern for nurses, hospital administrators, policy makers, and consumers. Magnet Hospital accreditation is increasingly recognized as a symbol of hospitals that promote a positive nursing work environment which supports quality patient care and nurse satisfaction. While research from nursing, organizational, patient safety, and occupational health perspectives has examined many work environment factors, no research has simultaneously examined the effect of Magnet hospital attributes and occupational health models on nurse satisfaction. Purposes. (1) explore the relative influence of the Magnet hospital attributes and psychosocial work environment models on nurses' job satisfaction, and (2) identify the potential moderation effects of occupational health models. Methods. Using a cross-sectional design, the study examined baseline data from the European Nurses Early Exit (NEXT) Study, a multi-country study of nurses' work conditions and turnover conducted between 2002 and 2005. Registered staff nurses working in acute care settings from 31 hospitals in Belgium and Germany (N=3182) were studied. Measurement models were established using structural equation modeling and a multilevel approach that accounts for the nesting of nurses within hospitals. Magnet hospital attributes [MH] and job satisfaction [JS] were modeled as latent factors and demand-control-support [DCS] and effort-reward imbalance [ERI] were modeled as latent classes. Analysis was conducted with Mplus 4.21 and SPSS 12.0. Results. Consistent with findings in other countries, about 70% of these European hospital nurses reported high job demand and 40% reported high job strain. Variation in satisfaction was significantly explained by most MH attributes. At the individual level, personnel policies (primarily representing pay and organizational support) had the strongest influence on satisfaction. At the hospital level, management style had the strongest influence. When the occupational health models (DCS and ERI) and MH models were examined simultaneously, no moderation effects were found. The main effect of ERI had the strongest influence on JS as compared to DCS and MH, supporting the imbalance between nurses high work demands (effort) and control and support (reward). Conclusion. While the Magnet hospital attributes evolved in the U.S., they are relevant to European hospital nursing practice in Belgium and Germany. Likewise, these hospital nurses face high demands and experience high job strain, which must be addressed by nursing leaders and hospital administrators. Hospital nurse environment research must use multilevel modeling to better isolate the effects at the individual, work group, and hospital level.