Costs, outcomes and estimation of the cost-effectiveness of abciximab in the prevention of ischemic events over six months of follow-up
AuthorReed, Shelby Ogilvie
AdvisorMullins, C. Daniel
MetadataShow full item record
AbstractAbciximab 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.
DescriptionUniversity of Maryland, Baltimore. Pharmacy Administration. Ph.D. 1998
KeywordHealth Sciences, Medicine and Surgery
Health Sciences, Pharmacy
Health Sciences, Public Health
Health Sciences, Health Care Management
Platelet Aggregation Inhibitors--economics
Platelet Aggregation Inhibitors--therapeutic use
Identifier to cite or link to this itemhttp://hdl.handle.net/10713/1351
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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 systemCorey-Lisle, Patricia Katherine; Trinkoff, Alison M. (2000)In 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.
Development of a measure of the content and quality of prenatal care services in a Medicaid populationNewcomer, Wendy Elizabeth; Soeken, Karen (1996)Statement 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.
Patterns of psychopharmacologic treatment for attention deficit hyperactivity disorderdosReis, Susan; Zito, Julie Magno (1999)Outpatient office visits and stimulant medication treatments for attention deficit hyperactivity disorder (ADHD), the most common childhood psychiatric disorder, show sizeable increases in the US from 1990-1995. Current research findings do not fully explain the increases in diagnostic and treatment prevalence. Descriptive information of ADHD treatments across different youth populations would inform how clinical, demographic, and cultural factors influence treatment practices. This study examines child characteristics, parental perceptions, and health care system factors associated with ADHD medication treatment to understand their role in clinical decision-making. The specific aims of the study are to: compare ADHD treatment patterns for health maintenance organization (HMO) child members with Medicaid child members in the same geographic region; describe ADHD treatment referral patterns among a sample of school-aged children in an HMO; and survey parents' knowledge, attitude, and satisfaction with their child's ADHD treatment. Data were obtained from HMO and Medicaid computerized medical and prescription databases and a self-administered Attitude, Satisfaction, Knowledge and Medication Experiences (ASK-ME) survey for parents of children with ADHD. Findings from the computerized data show that HMO youths receiving care from a non-mental health provider were 4 times more likely to be diagnosed with ADHD than Medicaid youths. The survey study findings revealed that Caucasian parents had significantly greater knowledge of and more positive attitudes towards ADHD medication treatment. A larger proportion of non-Caucasian than Caucasian parents preferred counseling over medication and believed that stimulant medication led to substance abuse. Parents in both groups had false expectations about the medication's ability to improve the child's academic performance and behavior later in life. Parents were less satisfied with the medication's ability to enhance their child's self-esteem and social relations at home and at school. This study identified health care system, clinical, economic, and racial differences in perceptions of and treatments for ADHD among HMO and Medicaid youths. Additional research that includes a broader range of racial, cultural, and economic characteristics is needed to corroborate these findings. This work is important for the advancement of scientific knowledge of pediatric psychopharmacologic practices and for improvement in the clinical management of children with ADHD.