The Cost of Reaching National Cholesterol Education Program (NCEP) Goals in Hypercholesterolaemic Patients: A Comparison of Atorvastatin, Simvastatin, Lovastatin and Fluvastatin

Objective: Recognising the importance of treating hyperlipidaemia, the National Cholesterol Education Program (NCEP) has established widely accepted treatment goals for low density lipoprotein cholesterol (LDL-C). Medications used most commonly to achieve these LDL-C goals are HMG-CoA reductase inhibitors. The relative resource utilisation and cost associated with the use of reductase inhibitors of different LDL-C lowering efficacy are unknown, but are major health and economic concerns. The objective of this study was to determine the mean total cost of care to reach NCEP goals with various reductase inhibitors. Design: In a randomised, 54-week, 30-centre controlled trial we compared resources used and costs associated with treating patients to achieve NCEP goals using 4 reductase inhibitors: atorvastatin, simvastatin, lovastatin and fluvastatin. Patients and participants: The trial studied 662 patients; 318 had known atherosclerotic disease. Interventions: Reductase inhibitor therapy was initiated at recommended starting doses and increased according to NCEP guidelines and package insert information. For patients who did not reach the goal at the highest recommended dose of each reductase inhibitor, the resin colestipol was added. Main outcome measures and results: Patients treated with atorvastatin, compared with other reductase inhibitors, were more likely to reach NCEP goals during treatment (pPharmacoeconomics, Guideline-utilisation, Hypercholesterolaemia, Fluvastatin, Lovastatin, Atorvastatin, Simvastatin, Cost-analysis, Randomised-controlled-trials, Clinical-trial-design, Hmg-coa-reductase-inhibitors, Drug-utilisation

Toward A Second-Generation Theory of Fiscal Federalism

Drawing on a wide range of literature and ideas, a new “second-generation theory of fiscal federalism” is emerging that provides new insights into the structure and working of federal systems. After a restatement and review of the first-generation theory, this paper surveys this new body of work and offers some thoughts on the ways in which it is extending our understanding of fiscal federalism and on its implications for the design of fiscal institutions. Copyright Springer Science + Business Media, Inc. 2005fiscal federalism, fiscal competition, regional and local governments,