Polymorphisms and the pocketbook: the cost-effectiveness of cytochrome P450 2C19 genotyping in the eradication of Helicobacter pylori infection associated with duodenal ulcer

The clinical outcome of duodenal ulcer treated with proton pump inhibitor (PPI)-based, anti-Helicobacter pylori (H.p.) regimens varies according to cytochrome P450 2C19 (CYP2C19) genotype. CYP2C19 genotypes differ markedly in peoples of Pacific Rim descent compared with another ethnicity. The authors sought to determine the specific impact that these factors have on the cost-effectiveness of duodenal ulcer management. Their model consisted of two patient cohorts with Helicobacter pylori and duodenal ulcer, trichotomized into CYP2C19 homozygous extensive metabolizers (EMs), heterozygous EMs, and poor metabolizers (PMs), altering the anti-H.p. regimen in the genotyped cohort only. The authors took the perspective of a third-party payer, and the denominator was ulcer episode prevented. In the reference case, the use of CYP2C19 genotyping prior to initiating anti-H.p. therapy was dominant (costs were saved with each ulcer episode prevented) in all geographic regions of the United States. The subsequent break-even analysis showed a range of 89.20 dollars to 118.96 dollars--from Hawaii to the Midwest, respectively--required to eliminate the cost-savings from each genotype test performed. Using probabilities most unfavorable to genotyping, the variation of peoples with Pacific Rim origins from 0% to 100% altered the cost-effectiveness from 495 dollars to 2125 dollars per ulcer event prevented, respectively. The results suggest that treatment decisions for H.p. infection that are based on a patient\u27s CYP2C19 genotype decreases expenses for health plans implementing testing. This analysis provides an economic basis to support recent calls to expand this technology into routine clinical care to prevent toxicity of narrow therapeutic index drugs

Cost reduction and outcome improvement in the intensive care unit

OBJECTIVE: Decreasing reimbursement provided by third-party payors necessitates reduction of costs for providing critical care services. If academic medical centers are to remain viable, methods must be instituted that allow cost reduction through practice change. METHODS: We used short cycle improvement methodology to rapidly achieve these goals. Short cycle improvement methodology involves identifying the areas for improvement, defining a mechanism to evaluate outcome, initiating an improvement plan on a small number of patients, and repeating the cycle with new adjustments based on outcome. Baseline data on areas for improvement was prospectively collected, and protocols to initiate change were developed and tested by short improvement cycles. Outcomes were evaluated, protocols were modified, and another cycle was performed. This methodology was continued until the desired goals had been achieved. To adjust outcomes for severity of illness, Acute Physiology and Chronic Health Evaluation II methodology was used. Using this methodology, we focused on three areas for improvement. Standing orders for laboratory studies, electrocardiograms, and chest x-ray films were eliminated. Protocols were developed for the appropriate use of sedation, analgesics, and neuromuscular blocking agents. Finally, a protocol for weaning from mechanical ventilation was developed to allow respiratory therapists to proceed through the weaning process, which was ordered by a physician. RESULTS: Laboratory tests were reduced by 65% (from 510 to 180 tests per day) with an annual cost savings of $21,593. Chest x-ray reduction of 56$3,941. There was a 75% reduction in cost of neuromuscular blocking agents. The use of neuromuscular blocking agents resulted in a 75% reduction in drug costs. Ventilator hours were reduced by 35% from 140 to 90 hours. The average length of overall intensive care unit stay was reduced by 1.5 days (5.0 to 3.5 days). The cost per patient day decreased with an annualized cost savings of 4% per patient day. Unexpected outcomes included a reduction in intensive care unit days from 54 days at baseline to 7 days at the 6-month interval. The infection rates for blood stream infections, urinary tract infections, and nosocomial pneumonia were reduced. Using national nosocomial infection data, these rates represented a reduction from the fiftieth percentile to the twenty-fifth percentile for all measured indicators. Acute Physiology and Chronic Health Evaluation II scores were 19.54 at baseline and increased to 21.2 (p = 0.001) at the 6-month interval. Mortality rates were 16.7% at baseline and were 17.6% (p = 0.89) at the 6-month interval. CONCLUSION: We concluded that utilization of short cycle improvement methodology provided an ongoing method for reducing costs of critical care services in our patient population with no change in mortality