A review of the benefits and risks of nonsteroidal anti-inflammatory drugs in the management of mild-to-moderate osteoarthritis

This review is intended to provide physicians with an overview of the benefits and risks associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of their patients with mild-to-moderate osteoarthritis (OA). New information on the inflammatory component of OA and the cardiovascular (CV) risk associated with cyclooxygenase (COX)-2-specific inhibitors has prompted efforts to revise the current recommendations for the use of NSAIDs in the treatment of patients with OA. Clinical studies have shown that naproxen and ibuprofen are significantly more effective at reducing OA pain than is acetaminophen, the traditional first-line therapy, which has no apparent anti-inflammatory activity in the joints. The theoretical advantage of COX-2-specific inhibitors in reducing gastrointestinal (GI) toxicity has been demonstrated by clinical studies. GI complications can be reduced by using lower NSAID doses for the shortest duration or with a concomitant proton-pump inhibitor. All prescription NSAIDs carry a black box warning regarding CV risks; these risks vary among the NSAIDs. While ibuprofen and diclofenac are associated with an increased CV risk, naproxen was associated with a neutral CV risk relative to placebo. Ibuprofen, but not naproxen, attenuates the antiplatelet effects of aspirin. An understanding of the risks and benefits is important when choosing an NSAID. An exhaustive search of the medical literature since 1990 was conducted using the words "ibuprofen," "naproxen," "COX-2-specific NSAIDs," "nonspecific NSAIDs," "low-dose aspirin," and "nonprescription dosage." Databases searched included MEDLINE, EMBASE, and SCISEARCH. This article provides primary care physicians with the information needed to assist them in making more informed decisions in managing patients experiencing mild-to-moderate OA pain

OTC analgesics and drug interactions: clinical implications

The risk of drug interactions with concurrent use of multiple medications is a clinically relevant issue. Many patients are unaware that over-the-counter (OTC) analgesics can cause potentially serious adverse effects when used in combination with other common medications such as anticoagulants, corticosteroids, or antihypertensive agents. Of particular significance is the increased risk of upper abdominal gastrointestinal adverse events in patients who take traditional nonsteroidal anti-inflammatory drugs (NSAIDs). This risk is dose dependent and further increased in patients who take more than one NSAID or use NSAIDs in combination with certain other medications. Some NSAIDs may also mitigate the antiplatelet benefits of aspirin and may increase blood pressure in patients with hypertension. Clinicians should be aware of potential drug interactions with OTC analgesics when prescribing new medications. Additionally, patients should be properly counseled on the appropriate and safe use of OTC analgesics

Health Savings Account - Eligible High Deductible Health Plans: Updating the Definition of Prevention

High-deductible health plans (HDHPs) are an important and growing part of the health insurance landscape. By some estimates, as many as 80 percent of large employers may offer an HDHP in 2014. In 2013, more than 15 million Americans received health coverage through an HDHP, a more than a threefold increase since 2007.As outlined by the U.S. Treasury Department, individuals with an HSA-eligible HDHP are required to pay the full cost of most medications and services -- in theory utilizing pre-tax HSA funds -- until deductibles are met. However, the 2003 authorizing legislation and further guidance include a safe harbor allowing plans to cover primary preventive services, those typically deemed to prevent the onset of disease, before the deductible is satisfied.Services or benefits meant to treat "an existing illness, injury or condition," are excluded from first-dollar coverage in HSA-eligible HDHPs, which encompasses most secondary preventive services. For example, plans are prohibited from providing first dollar coverage of disease management services such as insulin, eye and foot exams, and glucose monitoring supplies for patients with diabetes.As chronic disease conditions currently make up 75 percent of total U.S. health spending, appropriate chronic disease management is an important tool to lower long-term health care costs. As the market for HDHPs grow, it is important that they maintain the flexibility to allow for effective health management of all beneficiaries. This report addresses the strict definition of prevention that an HDHP must follow for it to include a pre-tax health savings account (HSA), and how this restriction limits the effectiveness of current plans. A potential solution - allowing HSA-eligible HDHPs to provide first-dollar coverage for targeted, evidence-based, secondary preventive services that prevent chronic disease progression and related complications - can improve patient-centered outcomes, add efficiency to medical spending, and enhance HDHP attractiveness.A multi-disciplinary research team from the University of Michigan's Center for Value-Based Insurance Design, Harvard Medical School, and the University of Minnesota conducted a multi-part project to investigate the impact of updatingthe definition of prevention for HDHPs to include selected secondary preventive services that are frequently used as health plan quality metrics and included as elements of pay-for-performance programs. Specifically, the project aimed to: 1) determine the premium effect, actuarial value, and estimated market uptake of the novel HDHP plan that covers these evidence-based services outside the deductible, and 2) explore through interviews whether insurance industry experts found coverage of secondary preventive services a worthwhile endeavor

Improving Health Outcomes for Patients with Depression: A Population Health Imperative. Report on an Expert Panel Meeting

Improving Health Outcomes for Patients with Depression: A Population Health Imperative. Report on an Expert Panel Meeting Janice L. Clarke, RN, Alexis Skoufalos, EdD, Alice Medalia, PhD, and A. Mark Fendrick, MD Editorial: A Call to Action: David B. Nash, MD, MBA???S-2 Overview: Depression and the Population Health Imperative???S-3 Promoting Awareness of the Issues and Opportunities for Improvement???S-5 Cognitive Dysfunction in Affective Disorders???S-5 Critical Role of Employers in Improving Health Outcomes for Employees with Depression???S-6 Closing the Behavioral Health Professional and Process Gaps???S-6 Achieving the Triple Aim for Patients with Depressive Disorders???S-6 Improving the Experience of Care for Patients with Depression???S-6 Improving Quality of Care and Health Outcomes for Patients with Depression???S-7 Changing the Cost of Care Discussion from How Much to How Well???S-8 Panel Insights and Recommendations???S-9 Conclusion???S-10Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140195/1/pop.2016.0114.pd

Helicobacter pylori test-and-treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States

The Helicobacter pylori ( H. pylori ) “test-and-treat” strategy in uninvestigated dyspepsia is an effective alternative to prompt endoscopy. Our aims were to determine whether the combination of an educational session and availability of office-based H. pylori testing (test-and-treat intervention [TTI]) increases use of the test-and-treat strategy by primary care practitioners and whether it improves patient outcomes. Methods : We conducted a 1-yr prospective trial of patients with suspected peptic ulcer disease in six primary care centers, three with TTI and three designated as usual care controls (UCC). Results : H. pylori testing was performed in 81% of 54 TTI patients and in 49% of 39 UCC patients ( p = 0.004). TTI and UCC patients had similar gastroenterology referral rates (24% vs 33%, p = 0.33), endoscopy or upper GI radiography rates (30% vs 31%, p = 0.91), and primary care visits per patient (3.1 ± 2.8 vs 3.1 ± 2.6, p = 0.92). TTI patients were less likely than UCC patients to receive repeated antisecretory medication prescriptions (35% vs 66%, p = 0.003). Symptomatic status at 1 yr and satisfaction with medical care did not differ between groups. Median (and interquartile range) annualized disease-related expenditures per patient were $454 ($162–932) for TTI and $576 ($327–1435) for UCC patients ( p = 0.17). Conclusions : The combination of an educational session and availability of office-based H. pylori testing may increase acceptance of the test-and-treat strategy by primary care providers. It remains to be determined whether increased use of the test-and-treat strategy yields significant improvements in clinical and economic outcomes compared to usual care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74830/1/j.1572-0241.2002.07118.x.pd

The clinical and economic impact of alternative staging strategies for adenocarcinoma of the pancreas

Several innovative imaging modalities, including endoscopic ultrasound, have increased the number of available preoperative staging methods in patients with adenocarcinoma of the pancreas. Our goal was to estimate the clinical outcomes and cost-effectiveness of alternative staging strategies for pancreatic adenocarcinoma. METHODS : Decision analysis was used to simulate alternative staging strategies. Cost inputs were based on Medicare reimbursements; clinical inputs were obtained from the available literature. Model endpoints of interest were cost per curative resection and appropriateness of treatment allocation based on pathological stage. RESULTS : Endoscopic ultrasound followed by laparoscopy yielded the lowest cost per curative resection ($37,600) and minimized the number of unnecessary surgical explorations (5.4 per 100 patients staged). Requiring angiographic confirmation when endoscopic ultrasound demonstrated an unresectable tumor yielded an intermediate cost-effectiveness ratio and virtually eliminated the risk of overstaging. Laparoscopy alone maximized the resection rate, but each additional resection would cost approximately$2 million relative to a strategy employing both endoscopic ultrasound and angiography. CONCLUSIONS : Staging strategies incorporating endoscopic ultrasound may improve treatment allocation and are cost-effective relative to angiography-based strategies. A staging protocol that does not incorporate an imaging modality to detect vascular invasion dramatically increases the cost per additional curative resection compared with more comprehensive staging protocols.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74623/1/j.1572-0241.2000.02191.x.pd

COST-EFFECTIVENESS OF AIRLINE DEFIBRILLATORS: IS PEACE OF MIND MORE IMPORTANT THAN SAVING LIVES?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74922/1/j.1524-4733.2001.40201-5.x.pd

A randomized, controlled trial to assess a novel colorectal cancer screening strategy: the conversion strategy

Our study was a randomized, controlled trial to assess a novel strategy that provides comprehensive colorectal cancer screening in a single visit versus traditional sigmoidoscopy and, where appropriate, colonoscopy on a subsequent day. METHODS : Consecutive patients referred for screening were randomized to control or so-called “conversion” groups. Patients in the control group were prepared for sigmoidoscopy with oral phospho-soda. Those with an abnormal sigmoidoscopy were scheduled for colonoscopy on a future day after oral polyethylene glycol preparation. In the conversion group, patients were prepared with oral phospho-soda. Patients with a polyp >5 mm or multiple diminutive polyps were converted from sigmoidoscopy to colonoscopy, allowing comprehensive screening in a single visit. Clinical outcomes were assessed by postprocedure physician and patient questionnaires. RESULTS : Two hundred thirty-five patients were randomized (control = 121, conversion = 114). In the control group, 28% had an indication for colonoscopy. Three of 33 (9%) with an abnormal sigmoidoscopy did not return for colonoscopy. At colonoscopy, 27% had a proximal adenoma. In the conversion group, 28% had an abnormal sigmoidoscopy and underwent conversion to colonoscopy. Forty-one percent undergoing colonoscopy in the conversion group had a proximal adenoma. Physicians reported no differences in preparation or procedure difficulty, whereas patients reported no differences in the level of comfort or overall satisfaction between groups. When queried regarding preferences for future screening, 96% chose the conversion strategy. CONCLUSIONS : The conversion strategy led to similar outcomes compared to traditional screening while improving compliance with colonoscopy in patients with an abnormal sigmoidoscopy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73097/1/j.1572-0241.2000.02231.x.pd