Search

Contextβ-Blockers are underused in patients who have myocardial infarction (MI), despite the proven efficacy of these agents. New evidence indicates that β-blockers can have benefit in patients with conditions that have been considered relative contraindications. Understanding the consequences of underuse of β-blockers is important because of the implications for current policy debates over quality-of-care measures and Medicare prescription drug coverage.ObjectiveTo examine the potential health and economic impact of increased use of β-blockers in patients who have had MI.Design and SettingWe used the Coronary Heart Disease (CHD) Policy Model, a computer-simulation Markov model of CHD in the US population, to estimate the epidemiological impact and cost-effectiveness of increased β-blocker use from current to target levels among survivors of MI aged 35 to 84 years. Simulations included 1 cohort of MI survivors in 2000 followed up for 20 years and 20 successive annual cohorts of all first-MI survivors in 2000-2020. Mortality and morbidity from CHD were derived from published meta-analyses and recent studies. This analysis used a societal perspective.Main Outcome MeasuresPrevented MIs, CHD mortality, life-years gained, and cost per quality-adjusted life-year (QALY) gained in 2000-2020.ResultsInitiating β-blocker use for all MI survivors except those with absolute contraindications in 2000 and continuing treatment for 20 years would result in 4300 fewer CHD deaths, 3500 MIs prevented, and 45,000 life-years gained compared with current use. The incremental cost per QALY gained would be $4500. If this increase in β-blocker use were implemented in all first-MI survivors annually over 20 years, β-blockers would save $18 million and result in 72,000 fewer CHD deaths, 62,000 MIs prevented, and 447,000 life-years gained. Sensitivity analyses demonstrated that the cost-effectiveness of β-blocker therapy would always be less than $11,000 per QALY gained, even under unfavorable assumptions, and may even be cost saving. Restricting β-blockers only to ideal patients (those without absolute or relative contraindications) would reduce the epidemiological impact of β-blocker therapy by about 60%.ConclusionsOur simulation indicates that increased use of β-blockers after MI would lead to impressive gains in health and would be potentially cost saving.

ContextMammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.ObjectiveTo compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.DesignDecision analysis and cost-effectiveness analysis using a Markov model.PatientsGeneral population of women aged 65 years or older.InterventionsThe analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.Main Outcome MeasuresDeaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.ResultsCompared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10,000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66,773 per year of life saved. Continuing mammography to age 79 years in all 10,000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117,689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.ConclusionsThis analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.

New testing technologies – increasingly based on genomic information – are essential in the shift towards personalized medicine and molecular targeted therapies. Considering the rapid proliferation of new tests, healthcare insurers and policymakers are interested in assessing evidence about their use and value. It is critical to build an evidence base to support effective decision-making related to testing technologies as they are used in clinical practice. The example of human epidermal growth factor receptor 2 (HER2) testing for breast cancer illustrates the challenges and opportunities. Many groups, including the Institute of Medicine; Agency for Healthcare Research and Quality; Secretary’s Advisory Committee on Genetics, Health, and Society; President’s Council of Advisors on Science and Technology; and Evaluation of Genomic Applications in Practice and Prevention Project have cited the need to improve the evidence base for genomic and testing technologies. This Commentary extends previous work, emphasizing the need for evidence to assess how technologies are actually used in clinical practice.

ContextAdverse drug reactions are a significant cause of morbidity and mortality. Although many adverse drug reactions are considered nonpreventable, recent developments suggest these reactions may be avoided through individualization of drug therapies based on genetic information, an application known as pharmacogenomics.ObjectiveTo evaluate the potential role of pharmacogenomics in reducing the incidence of adverse drug reactions.Data SourcesMEDLINE English-language only searches for adverse drug reaction studies published between January 1995 and June 2000 and review articles of variant alleles of drug-metabolizing enzymes published between January 1997 and August 2000. We also used online resources, texts, and expert opinion.Study SelectionDetailed inclusion criteria were used to select studies. We included 18 of 333 adverse drug reaction studies and 22 of 61 variant allele review articles.Data ExtractionAll the investigators reviewed and coded articles using standardized abstracting forms.Data SynthesisWe identified 27 drugs frequently cited in adverse drug reaction studies. Among these drugs, 59% are metabolized by at least 1 enzyme with a variant allele known to cause poor metabolism. Conversely, only 7% to 22% of randomly selected drugs are known to be metabolized by enzymes with this genetic variability (range, P = .006-P