No abstract

Acute ambulatory- and hospital-billed charges for most patients with MS do not differ from those of the general population.

Objective. To determine the cost-utility of lowdose misoprostol prophylaxis in rheumatoid arthritis (RA) patients treated with nonsteroidal antiinflammatory drugs (NSAIDs).Methods. Prospectively collected, populationbased data on 57 RA patients' preferences (obtained using the category scaling and time trade-off techniques), charge data from a consecutive, populationbased cohort of 36 RA patients with NSAID-related gastric ulcer, and literature-derived probability estimates were incorporated into a decision analysis model. Results. Probabilistic sensitivity analysis using 10,000 Monte Carlo simulations demonstrated that, on average, prophylaxis resulted in modest additional costs and no additional quality-of-life benefits. At best, the incremental cost per quality-adjusted life year gained was $9,333. At worst, prophylaxis reduced quality of life. Prophylaxis was cost-saving if the ulcer complication rate was >1.5%, or if the 3-month price of misoprostol was ~$ 9 5 .Conclusion. Whereas prophylaxis may be costsaving among high-risk NSAID users, from some patients' perspective, it reduces quality of life. Although these data may not be generalizable to other clinical populations, they illustrate the importance of incorporating patient preferences into economic evaluations.An estimated 30 million people worldwide consume nonsteroidal antiinflammatory drugs (NSAIDs), constituting a world market in excess of $2 billion (1). NSAID-induced adverse gastrointestinal (GI) events, ranging from dyspepsia to severe complications that can lead to hospitalization, surgery, and death, have important negative effects on patient quality of life (2). While misoprostol (a prostaglandin analog) prevents the development of clinically defined NSAIDassociated gastric ulcers (3), its effectiveness on the clinically important outcomes of hemorrhage, perforation, and death is unknown, and it may result in reduced quality of life due to medication side effects. Therefore, widespread use of misoprostol prophylaxis (4) not only has potential important economic consequences to society but may also have important quality of life consequences. Of the 6 published economic evaluations of misoprostol prophylaxis (5-lo), 5 concluded that it was cost-effective. However, none of these analyses incorporated any measure of healthrelated quality of life.Using data from the literature (summarized in our metaanalysis [2]) buttressed with new populationbased estimates of costs and of rheumatoid arthritis (RA) patients' preferences (a measure of healthrelated quality of life) for all possible outcomes related to NSAID-associated gastric ulcers, we have designed a model to determine the impact on costs and on patient quality and quantity of life for 3 misoprostol prophylaxis strategies: 1) misoprostol prophylaxis for all NSAID users, 2) misoprostol prophylaxis for no NSAID users, or 3) prophylaxis for only elderly (highrisk) NSAID users.

No abstract

To address the paucity of patient-level data regarding the effectiveness of Medicare's prospective payment system (PPS), we conducted a population-based study of inpatient hospitalizations among individually identified elderly residents of Olmsted County, Minnesota, 1970-1987. A 4.3% increase in total days of care/1000 population from 2,652/1,000 in 1970 to 2,766/1,000 in 1980 was followed by a 9.8% decline from 1980 to 1987 (2,495/1,000). The decline was due primarily to a 13.4% decrease in mean length stay (9.7 days in 1980 to 8.4 days in 1987). The number of hospitalizations/1,000 Olmsted County elderly in 1980 was already below 1987 U.S. figures and did not exhibit the decline evidenced nationally between 1980 and 1987. A 4.6% decline in the proportion of county residents age 65-74 years who were hospitalized (174/1,000 in 1980 to 166/1,000 in 1987) was offset by an 8.3% increase for persons age greater than or equal to 75 (252/1,000 to 273/1,000) and by a 5.7% increase in the number of hospitalizations per individual hospitalized for persons age 65-74 years (1.34 to 1.42). Using a time-dependent Cox model, which adjusted for differences in patients characteristics between years, there was a significantly higher risk of readmission within 14 days in 1987 vs 1980 (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.05-1.70). The difference between years was no longer evident at 30 or 60 days (HR = 0.84, 95% CI = 0.63-1.11 between 15 and 30 days; HR = 1.12, 95% CI = 0.84-1.49 between 31 and 60 days). This study suggests that initial effects of PPS on utilization may be temporary and that more research is needed to appreciate the impact of cost-containment on patient outcome.