Search

Several letters to the editor are presented in response to an editorial in the previous issue which discussed the treatment management of hypertension.

Recent national recommendations have proposed that physicians should titrate lipid therapy to achieve low-density lipoprotein (LDL) cholesterol levels less than 1.81 mmol/L (<;70 mg/dL) for patients at very high cardiovascular risk and less than 2.59 mmol/L (<;100 mg/dL) for patients at high cardiovascular risk. To examine the clinical evidence for these recommendations, the authors sought to review all controlled trials, cohort studies, and case-control studies that examined the independent relationship between LDL cholesterol and major cardiovascular outcomes in patients with LDL cholesterol levels less than 3.36 mmol/L (<;130 mg/dL). For those with LDL cholesterol levels less than 3.36 mmol/L (<;130 mg/dL), the authors found no clinical trial subgroup analyses or valid cohort or case-control analyses suggesting that the degree to which LDL cholesterol responds to a statin independently predicts the degree of cardiovascular risk reduction. Published studies had avoidable limitations, such as a reliance on ecological (aggregate) analyses, use of analyses that ignore statins' other proposed mechanisms of action, and failure to account for known confounders (especially healthy volunteer effects). Clear, compelling evidence supports near-universal empirical statin therapy in patients at high cardiovascular risk (regardless of their natural LDL cholesterol values), but current clinical evidence does not demonstrate that titrating lipid therapy to achieve proposed low LDL cholesterol levels is beneficial or safe. [ABSTRACT FROM AUTHOR]

Management of diabetes, and in particular blood glucose, can be complex and burdensome. To evaluate patient views of the burdens of therapy and its impact on self-management. Veteran patients with type 2 diabetes. Mailed survey. Patients described their views of the burden of diabetes treatments, adherence, and clinical and demographic status. Factors associated with ratings of burden and adherence to therapy were examined using multivariate regression methods. The response rate was 67% ( n=1,653). Patients viewed pills as the least burdensome treatment and insulin as the most burdensome. Ratings of the burden of insulin were lower if a patient had prior experience with therapy. Adherence to prescribed therapy varied substantially; for example, patients followed medication recommendations more closely than other areas of self-management. Multivariate analyses showed that the main predictor of adherence was patients' ratings of the burden of therapy. Injected insulin regimens are viewed as highly burdensome by patients, although this burden is attenuated by experience. Adherence to self-management is strongly and independently correlated with views of treatment burden. The burden of diabetes-related treatments may be a source of suboptimal glucose control seen in many care settings. Providers should consider the burden of treatment for a particular patient and its impact on adherence as part of a decision-making process to design effective treatment regimens. [ABSTRACT FROM AUTHOR]

Objective: We sought to explore the patient-specific cost-effectiveness in a community-based sample for a therapy for which the average cost-effectiveness in a clinical trial has been well-described.Study design and setting: Based on a validated multivariate model, we generated predictions of the effectiveness and cost-effectiveness of t-PA compared to streptokinase on 921 consecutive patients who received thrombolytic therapy for acute myocardial infarction.Results: The average cost-effectiveness of t-PA was $40,140 per life-year saved. For the quartile of patients most likely to benefit, the incremental cost-effectiveness of t-PA was $15,396. However, only 44% of patients who received thrombolytic therapy had an estimated cost-effectiveness ratio below $50,000 per year of life saved; the ratio was greater than $100,000 in 37% of treated patients. Patients in the lowest quartile of expected benefit are, overall, more likely to be harmed than to benefit from t-PA.Conclusion: Compared to the pattern of thrombolytic agent choice observed, targeting t-PA to the half of patients most likely to benefit could save 247 lives and $174 million nationally per year. [Copyright &y& Elsevier]

Evaluates goals and optimal agents for treatment of hypertension in type 2 diabetes. Review of the medical literature to obtain data; Extraction and synthesis of data for the study; Benefits of blood pressure control; Recommended blood pressure level and hypotensive agents.

Background & Aims: Guidelines recommend that patients with colon adenomas undergo periodic surveillance colonoscopy. The purpose of this study was to estimate the cost-effectiveness of these recommendations. Methods: We developed a Markov model to study various surveillance strategies from the perspective of a long-term payer. We modeled a cohort of 50-year-old patients with newly diagnosed adenomas, following them until death. Thirty percent of the population was assumed to be at high risk for colorectal cancer. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured. Results: Performing colonoscopies every 3 years in high-risk patients and every 10 years in low-risk patients (3/10 strategy) was more costly but also more effective than no surveillance, with an ICER of $5743 per QALY gained. Compared with this 3/10 strategy, a 3/5 strategy was considerably more costly but only marginally more effective, with an ICER of $296266 per QALY. A 3/3 strategy was more costly and less effective than a 3/5 strategy (dominated). Results were most sensitive to the annual probability of advanced adenoma formation and the relative risk (RR) of advanced adenoma formation in high-risk versus low-risk patients. Assuming that the probability of advanced adenoma formation was 1.3% per year (base: 0.5%), the ICER of the 3/5 strategy was <$50000 per QALY gained if the RR of advanced adenoma formation was <2.4 (base: 3.9). Conclusions: Surveillance colonoscopy is cost-effective for patients who are at high risk for developing colorectal cancer. Aggressive surveillance can be expensive or even harmful; efforts should be made to improve risk models for colonic neoplasia. [Copyright &y& Elsevier]