The cost-effectiveness of different management strategies for patients on chronic warfarin therapy

Lafata, Jennifer Elston; Martin, Susan; Kaatz, Scott; Ward, Richard E.

doi:10.1046/j.1525-1497.2000.01239.x

Cited by 74 publications

(62 citation statements)

References 45 publications

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“…Informal caregiver time costs will also be important inputs in cost-effectiveness analyses (CEAs), as recommended by The Panel on Cost-Effectiveness in Health and Medicine, 8 particularly when comparing healthcare strategies or interventions that differentially rely on informal caregivers. Few studies have explicitly assessed the impact of including time costs in CEAs, [27][28][29] and in some situations, the optimal strategy can vary depending on whether these costs are included or excluded. 27,28 For example, investigators reanalyzed the cost-effectiveness of self-monitoring of blood glucose by patients with type 2 diabetes taking oral antidiabetic medicine compared with no self-monitoring, and found that inclusion of patient time changed the cost-effectiveness ratio from $23,380 per quality-adjusted life-year (QALY) to $76,340 per QALY over a 5-year horizon.…”

Section: Discussionmentioning

confidence: 99%

“…Few studies have explicitly assessed the impact of including time costs in CEAs, [27][28][29] and in some situations, the optimal strategy can vary depending on whether these costs are included or excluded. 27,28 For example, investigators reanalyzed the cost-effectiveness of self-monitoring of blood glucose by patients with type 2 diabetes taking oral antidiabetic medicine compared with no self-monitoring, and found that inclusion of patient time changed the cost-effectiveness ratio from $23,380 per quality-adjusted life-year (QALY) to $76,340 per QALY over a 5-year horizon. 27 To our knowledge, no studies have explicitly evaluated the impact of including and excluding caregiver time costs.…”

Section: Discussionmentioning

confidence: 99%

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Time costs associated with informal caregiving for cancer survivors

Yabroff¹,

Kim²

2009

Cancer

262

216

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BACKGROUND:To the authors' knowledge, little work has been done to estimate the time costs associated with informal caregiving for cancer survivors.METHODS:Data from a national survey of caregivers of cancer patients in 2003 to 2006 were used to estimate the time associated with informal caregiving in the 2 years after patient diagnosis with bladder, breast, colorectal, kidney, lung, melanoma of the skin, ovarian, prostate, or uterine cancer, or non‐Hodgkins lymphoma (NHL). Caregivers reported the duration and daily intensity of caregiving as well as the types and frequency of support provided. The median wage rate in 2006 ($16.28) was used to value caregiver time, and other methods to value time were evaluated with sensitivity analyses.RESULTS:On average, caregivers provided care for 8.3 hours per day for 13.7 months. The number of months and daily hours spent caregiving were the highest for cancer survivors diagnosed with distant disease compared with survivors with regional or localized disease (P < .05). Approximately half of caregivers provided emotional, instrumental, tangible, or medical support, although the frequency varied dramatically. Informal caregiver time costs over the 2‐year period after diagnosis were the highest for caregivers of patients diagnosed with lung ($72,702; 95% confidence interval [95% CI], $56,814‐$88,590) and ovarian ($66,210; 95% CI, $40,750‐$91,670) cancers and NHL ($59,613; 95% CI, $43,423‐$75,803) and the lowest for caregivers of patients with breast cancer ($38,334; 95% CI, $31,442‐$45,226).CONCLUSIONS:Time spent by informal caregivers was substantial and was an important component of the burden of cancer care. Incorporation of the value of informal caregiver time will be important when evaluating the costs and benefits of cancer control interventions. Cancer 2009;115(18 suppl):4362–73. © 2009 American Cancer Society.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Time costs associated with informal caregiving for cancer survivors

Yabroff¹,

Kim²

2009

Cancer

262

216

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“…19 This is an even greater issue in routine medical care, where time in range has been documented to be even lower. 20,21 An effective low-risk therapy that could eliminate the need for OACs and their associated risks to the patient is therefore very attractive.…”

Section: Response By Holmes and Schwartz On P 1932mentioning

confidence: 99%

Left Atrial Appendage Occlusion Does Not Eliminate the Need for Warfarin

2009

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A trial fibrillation (AF) is the most common sustained heart rhythm disorder. It is increasing in incidence, which has major societal implications for our aging population. [1][2][3] It is estimated to affect 1% to 1.5% of the developed world, and the incidence increases with age to a rate of 19.2 per 1000 patient-years in those 65 years of age and older. The most important aspect of the treatment of patients with AF is the prevention of stroke. The average annual stroke rate across risk groups is 5%, and AF-associated strokes confer worse outcomes than those occurring in the absence of AF. 1,4 Furthermore, Stroke Prevention in Nonrheumatic Atrial Fibrillation (SPINAF) data suggest that 15% of patients with AF suffer silent cerebral infarctions on computed tomography, the implications of which are unknown. 5 Response by Holmes and Schwartz on p 1932Oral anticoagulant (OAC) therapy with warfarin has been established as the standard for stroke prevention in patients with AF and more than 1 risk factor for stroke. 6 Hart et al have summarized this literature in meta-analyses that include 29 trials and 28 044 patients. 7,8 Compared with placebo, warfarin reduced the rate of stroke by 64% (95% confidence interval [CI], 49% to 74%), and in trials of warfarin versus antiplatelet, warfarin reduced the rate of stroke by 37% (95% CI, 23% to 48%). This is a large treatment effect when compared with other drug therapies in cardiovascular medicine. Further, even with an absolute risk increase in intracerebral hemorrhage and major hemorrhage of 0.2% per year over antiplatelet therapy, warfarin still produces a statistically significant 26% reduction in overall mortality compared with placebo. 7 Despite its demonstrated benefit, warfarin therapy is administered to as few as 25% of patients with AF and only to 70% of patients who are considered to be "ideal" candidates for warfarin. 9 -15 In the Canadian Cardiovascular Outcomes Research Team AF study, using prescription claims databases in Alberta, British Columbia, and Ontario from 1997 to 2000 (pre-AFFIRM [Atrial Fibrillation Follow-up Investigation of Rhythm Management] trial), less than one half of patients with AF filled a prescription for warfarin within 90 days of discharge for an AF hospitalization. 13 Also concerning is the rate of warfarin discontinuation, which has been documented in the the Fibrillation Registry Assessing Costs, Therapies, Adverse events and Lifestyle (FRACTAL) as 20% over a 2.5-year period. 14 Many patient, prescriber, and system barriers have been identified. However, the main limitation of warfarin is concern about bleeding, and this often prevents its use in potentially suitable patients. 16,17 In study patients assigned to warfarin therapy, it has been noted that patients are in the therapeutic range on only 50% to 68% of monitored days. 18 The relationship between international normalized ratio (INR) and outcomes has been well documented: that low INR results in an increased risk of stroke and high INR is associated with increased risk of ble...

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“…Whether patient self-testing offers overall cost savings compared to either UC or care through an AMS has been evaluated by Lafata et al [65]. Annual anticoagulation management costs per patient were estimated to be $396, $753, and $860 for UC, care through an AMS, and self-testing, respectively.…”

Section: Costsmentioning

confidence: 99%

Home prothrombin time monitoring: A literature analysis

2004

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The anticoagulant activity of warfarin sodium is monitored by the prothrombin time (PT) using the international normalized ratio (INR). Standard oral anticoagulant therapy monitoring requires frequent patient visits to physicians' offices and/or laboratories to optimize warfarin dosage. Home PT monitoring by patients can increase testing frequency and may thus decrease complications associated with oral anticoagulant therapy. Clinical studies suggest that home PT monitoring is more effective than uncoordinated management and is as effective as care through specialized anticoagulation clinics for keeping INRs within a therapeutic range. There are accurate and reliable instruments available, but paramount to the success of home PT monitoring is sound patient selection, appropriate patient training, and consistent quality control. Am.

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The cost-effectiveness of different management strategies for patients on chronic warfarin therapy

Cited by 74 publications

References 45 publications

Time costs associated with informal caregiving for cancer survivors

Time costs associated with informal caregiving for cancer survivors

Left Atrial Appendage Occlusion Does Not Eliminate the Need for Warfarin

Home prothrombin time monitoring: A literature analysis

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