10 I N T ER NA TION AL R ESEA RCH & O P I N IO N

Unwananted variation in follow-up charges after colorectal cancer therapy

Charges for different follow-up strategies after treatment for colorectal cancer can vary by as much as 28-fold; such variation cannot be justified in this era of cost conlainment and hcalthcare system reform. comment US-based investigators. I

The investigators estimated 1992 nationwide charge data associated with the use of 11 different follow-up strategies over a 5-year period for patients with colorectal cancer. The follow-up strategies were selected from the available literature.

Medicare charges for 5 years' follow-up ranged from SUS561/patient using barium enema alone (a recom mendation of the American Society of Colon and Rectal Surgeons) to SUS 16 4921patient. using an intensive strategy. An intensive strategy would include multiple physician visits. faecal occult blood tests. complete blood cell counts, serum carcinoembryonic antigen tests , chest x·rays, colonoscopy procedures and liver ultrasound tests. The range of actual charges for the various s trategies using ) 995 values was estimated at SUS IOSJ-SUS31 733/patient.

Frequent colonoscopy increased costs Strategies consisting of frequent colonoscopy

during the 5· year period were costly. while those consisting of some combination of physician visi ts, faccal occult blood tests, complete blood cell counts, liver function tests. carcinoembryonic antigen tests and/or chest x·rays were generall y the least costly options.

The wide variation in charges for follow·up strategies emphasises the need for long· tenn, randomised trials. comparing various in tensities of follow-up to determine whether hi gh costs are warranted by improvements in quality of life and survival. say the investigators.

Need for evidence-based guidelines In an accompanying editorial . Dr Charles Loprinzi

highlights the need fo r the use of evidence-based guidelines as part of an organised strategy for fo llow·up of patients treated for cancer.2 He points out. however. that the development of guidelines fo r colorectal cancer survivors is likely to be difficult as there arc limited data on the utility of fo llow-up strategies for this cond ition.

Dr Lopri nzi believes that i t is inappropriate to perform freq uent blood and imaging tests during the firs t year after colorectal cancer therapy. During this period, most cancer recurrences are un likely to be resectable for cure; surgically resectable recurrences are most likely to be detected 2-4 years after initial therapy. He suggests that ultrasound imaging of the liver may be a sensitive and 'cost-conscious ' test to usc 2-4 years after initial therapy.

I. VIfIO KS. et al. C051 of JMlicnl follow-up aflCf poICntially cu.rative ~tal cancer U!:&lIl"IeD~ Journal of the Afneric,an Mcdio;aI Auo;i.atioa 27); 18)7-1&41 .21 Jlln 1995 1. Lq:rinriQ.. Follow ·up~ for cu.rati\'l'ly treated cancer survivon; wlw 10 do1.1oo.anal ofihl: Aml::ric;an McdQl Association 273: 1877-1878.21 JIID 1995 _ , ....

• Jul 1815 PHARM.t.CORESOURCES

Home antineoplastic therapy reduces costs and improves QOL

High-technology home care is a 'cost-effective' approach to healthcare delivery for children with cancer, say US-based researchers. Quality of life (QOL) for the patient and family also appears to be maintained with home care. compared with hospital care. they add .

Thei r analysis involved 14 children (aged 31 months to 16 years) with cancer and their families. Patients initially each received 2 courses of antineo­plastic therapy in hospital. 11lcy subsequently received a total of 76 courses of antineoplastic therapy at home. thereby avoiding 312 additional days' hospitalisation. QOL for patients and their fami lies, and the daily costs associated with an ti neop lastic therapy at home and in hospital were assessed from the parents' perspective.

Daily costs associated with antineoplastic therapy (SUS)

" '" 1.000 10,000

Coal/day ($US) ._----_.-Patients were perceived as experiencing greater

well-being, appetite. contentment, ability to complele school work and independence during home care than when they were in hospital. Home care was also associated with a significant improvement in parents' ability to perform household tasks, maintain their jobs and spend time with their spouses and other children, compared with hospital care. Patient and parental acceptance o f home care was high .

There was a 17% decrease in the lotal mean dail y costs attributed to antineoplastic therapy adminiSlered at home, compared with that administered in hospital (see figure] . The acquisition cost of antineoplastic therapy accounted for the greatest expense.

Close P. Burkey E. Kazak A. Dlnz P, Lan~ B, et al. A ~ye,

cOl1lrol1ed evaluation of home chemotherapy for chikln:n with cancer. Pedialric~ 95: 1196·900. J\ln 199~ _...,.

1rends in antihypertensive drug use in the elderly

Examination of prescribing trends for antihyper­tensive agents in the elderly between 1982 and 1988 reveal s substantial changes in the frequency of use of each drug class, say researchers from Harvard Medical School. Boston , US.

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I NTE RNATI ONAL R ESEA R C H & OPI N I ON

Their slUdy involved 8428 elderly patients (mean age 77 years) who were enrolled in the New Jersey Medicaid and Medicare programmes during 1982-88.

During the 7·year period, the proportion of initial prescriptions for diuretics decreased from 59% to 33% of all new antihypenensives. whereas those for calcium antagonists increased from 7% to 28%. There was also an increase in the proportion of initial prescriptions for ACE inhibitors (0.3% in 1982 and 16% in 1988). 1llere was no change in the proportion of first prescrip­tions attributed to \3-blockcrs: however. there was a definite swi tch from the use of noncardiosclective to cardioselective ~-blockers during the period.

Decreased use of diuretics The decreased use of diuretics as frrst-line therapy

occurred despite confirmation of the efficacy of this drug class in several large clinical trials.· Deter­minants of diuretic use included the year of initiation of antihypertensive therapy, older age, female sex and black race.

The rapid increase in the use of the newer and morc costly antihypertensives (i.e. calcium antagonists and ACE inhibitors) is likely to increase the cost of caring for patients with hypertension, according to the researchers. This may subsequently lead to a dete rioration in health outcomes as patients may not be able to afford these costly agents, resu lling in poor SP control and an increased incidence of complications , they add.

Trends towards the prescribing of crucium antagoni sts and ACE inhibitors 'present a concern relevant to policymakers, physicians and patients alike', comment the researchers.·· • See PlwrmacoResources 29: /0,27 May 1995 •• See PlwrmacoResources 29: 7, 27 May 1995 M~ M. GIYM RJ . Gurwitz JH. Bolm RL Levin R, et aI. Tn:nds in medication choices tOf hypmcllsion in the elderly: the <b:linc of the lhiazidcs. llypcrtcnsion 2.5: 1{\45· 1051. May 199~ _

Did you knOW • •• ?

Glaucoma is a relatively common condition in the elderly population, ac:cording to reseaIChers lrom the Centre lor Health Economics at the University 01 YOfk, UK. However, the OJrrent level 01 medical resources devoted to its treatment is lower than many other diseases. • The total cost 01 glaucoma In the UK in 1990 was

estimated to be £132.5 mMlion; medical costs aocot..rlted lot 46% 01 the total (£61 million).

• In oomparison, the estimated med'1CaI costs of IJeating Parldnson's disease and depression were £126 milan and £333 million, respectively, in 1990 while that lor treating aillorms 01 arthritis In 1989 was £495 million.

• Open-angle gtauccma, the most common form 01 the disease, is present in 0.5--1% 01 the UK population aged " 40 years. The prevalence 01 glaucoma in the general population Is estimated to be 024%.

• It has been estimated that up to 50% of Individuals in the UK who need drug therapy lor glaucoma remain untreated.

Coyle D, DnlnllQOIId M . The economic burden of ~ = the UK.: Ibr: IIC!Cd for • r.·.;pa:..t poIiq. ~ 1: 484489, JWI 1995 _

Keep in mind the iatrogenic costs of NSAID therapy

NSAlD-related gastrointestinal (GI) adverse effects may increase the cost of treatment with the 'least-safe' NSAID by 2.I-to 3.6· fold, according to G De Pouvourville of the Centre de Recherche en Gestion de I'Ecoie Polytechique in Descanes. France. Thus, the drug with the lowest acquisition cost may nOI be the least expensive treatment overall, he poi nts out.

He developed a model to cruculate the 'shadow prices' associated with piroxicam, naproxen and a fixed combination of diclofenac and misoprostol (see table). The 'shadow price' of an NSAID includes the acquisition cost of the drug and the direct medical costs of treating NSAID-related GI adverse effects. Cli nical trial data were used to calculate the total costs of these agents to the French national health insurancc system.

Iatrogenic cost factors associated with NSAID therapy (FF) T __ - ._-Plmxic:am: ..... ,,' , ... u

"""'" 1154.4 H -, .... '.6 -. ....,,,, 14C1.9 ... """'", '54' ,., -, "'. ,., ~:t"""''''_~ --, 148.1 U

......" 151.1 U -, "'" " , ~ CIIlC fador. ahaOoW ~ CIIlC 01 NSAlO

Acquisition costs associated with these 3 regimcns were FF69.60/paticnt/month fo r piroxicam, FF72.901 patient/month for naproxen and FF l37.25/patientJ month fo r diclofenac plus misoprostol. Three different scenarios were used to cruculate the 'shadow prices' and iatrogenic cost factors for the different NSAlDs.

1n scenario I , it was assumed that ru l NSAJD· related ulcers would require ambulatory treatment·. at a cost to the heruth insurance system of FF 13441 case. 1n scenarios 2 and 3, it was assumed that 1 % and 6% of patients with NSAID-related ulcer would requ ire hospitruisation, respectively, at costs of FF1612 and FF2957 per case.

<A lJhollgh tht shDdow price modt l is lIery simple. it rtlleais tht INJgnitwle of the economic conseqllences of the adllerse effects of NSAID thempy', comments G De Pouvourville. • including 2 endoscopies, 2 weeks 'therapy with anladds and 6 weeks' therapy with H2-antagOrlisu De i"wyourvilk O. The ia~ cost olllOll-~ anti· inflamnwory druS Ihenpy. BriIi$b Journal ofRJooeunwoklgy 3-' (Suppl. I ): 19.:Z4. A]W"

1995 _" ..

PHARMACORESOURCES • ..Iul 1,"

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