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Measuring the impact of managed care plans on the use of biologics.

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Arthritis & Rheumatism (Arthritis Care & Research)
Vol. 53, No. 3, June 15, 2005, pp 318 –319
DOI 10.1002/art.21168
© 2005, American College of Rheumatology
Measuring the Impact of Managed Care Plans on
the Use of Biologics
In this issue of Arthritis Care & Research, Yelin et al
examine the University of California, San Francisco Rheumatoid Arthritis Panel for differences in the use of specific
antirheumatic treatments, especially anti–tumor necrosis
factor (anti–TNF) agents, among patients in health maintenance organizations (HMOs), other managed care health
plans (preferred provider organizations or point of service
plans), and fee-for-service plans (Yelin EH, Trupin LS,
Katz PP. Impact of managed care on the use of biologic
agents for rheumatoid arthritis. Arthritis Rheum 2005;53:
423–30). The authors have been following these patients
since 1982–1983 using annual telephone interviews. Their
data now includes an impressive 11,669 person-years of
observation, although there has unfortunately been an
⬃65% attrition (⬃25% died, ⬃30% declined participation, and ⬃10% were lost to followup). There also appears
to be an ⬃20% turnover during each year, with 6 –10%
patients starting and 8 –10% stopping anti–TNF agents, for
This study has significant strengths, such as a long-term
followup and a clear and thorough analysis, which the
authors achieved by attempting to account for the abovementioned turnover. It also has some weaknesses, including the very significant attrition, the fact that all followups
are by telephone interview (introducing memory biases),
and the fact that one of the major control groups (the
fee-for-service group) comprises only 92 patients. Taking
into consideration these weaknesses, the authors point out
that allocation of certain medications differs between patients in HMOs, other managed care plans, and fee-forservice plans; namely, patients in HMOs use fewer biologic agents or cyclooxygenase 2 inhibitors than patients
in fee-for-service plans and are less likely than patients in
other managed care plans to start taking biologic agents.
This implies that this difference is the result of a bottomline orientation (i.e., the agents are expensive and there-
Daniel E. Furst, MD: University of California, Los Angeles.
Address correspondence to Daniel E. Furst, MD, UCLA
Division of Rheumatology, 1000 Veteran Avenue Room 3259, Los Angeles, CA 90095. E-mail: defurst@mednet.ucla.
Submitted for publication March 4, 2005; accepted March
6, 2005.
fore are used less frequently in patients in HMOs). This
analysis is used in other studies that show no differences
in other outcomes such as hospitalizations or joint surgeries. The results of this study are of real interest because
they investigate beyond the usual outcomes of joint replacements or hospitalizations.
One of the reasons that hospitalizations and joint replacements are used as outcomes is that they are clear
(dichotomous) and easy to record. Perhaps this study provides proof that other outcomes are also important for
patients with chronic conditions, such as rheumatoid arthritis (RA). It may well be the tip of an iceberg in that a
difference in the cost of biologic agents may represent a
surrogate for quality of life or productivity that goes beyond the high-altitude simple measures of cost of care
represented by hospitalizations or joint surgeries. Could
this difference, for example, be a surrogate for the ability to
maintain job productivity? Certainly such a connection is
possible; less use of biologic agents could lead to less
function, resulting in less ability to maintain employment
(either in or out of the home). In fact, employment status
has been examined in a previous study regarding biologic
agents (Yelin E, Trupin L, Katz P, Lubeck D, Rush S,
Wanke L. Association between etanercept use and employment outcomes among patients with rheumatoid arthritis.
Arthritis Rheum 2003;48:3046 –54).
The study by Yelin et al does not change the focus of the
research. It still examines cost of care from the societal, or
at least from the managed care organization’s point of view
rather than the individual’s point of view. Although the
larger view (societal) is valid, so is the individual’s view.
By examining biologic use, this study may open the way to
examining cost from the individual’s view point. Do patients who use biologic agents use fewer antidepressants,
anxiolytics, or analgesics? Do they use more antibiotics?
How do biologic agents affect depression, home function,
or social interactions? Although the Health Assessment
Questionnaire, the Arthritis Impact Measurement Scales,
and the Short Form 36 approach these issues and some of
their domains, more careful examination of these areas is
certainly justifiable and worthwhile from the patient’s
quality-of-life perspective.
It may be necessary to include more complete examinations in these long-term registries and observational cohorts, rather than simply conducting telephone inter-
views, so that other aspects of individual outcomes can be
examined. Databases such as Paulus’ Rheumatologist Consortium, the Consortium of Rheumatology Researchers of
North America database, or Rheumatoid Arthritis DiseaseModifying Anti-Rheumatic Intervention and Utilization
Study include more complete data on physical examinations, depression, and laboratory results, and they may
represent an additional route toward understanding the
effect of RA and its treatment on society and on patients
with RA.
Perhaps this study’s greatest importance is not in the
findings per se, but in the authors’ attempt to begin to
reflect on aspects of life that are different from those that
are usually examined (such as hospitalizations, mortality,
or joint replacements). It is clear that there continues to be
a need to search for valid ways to reflect the quality of life
of individuals with chronic diseases, such as RA, that do
not rapidly curtail the duration of life (although they may
do so, as well) but rather change the individual’s productivity and “joi de vie.”
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care, biological, measuring, use, plan, impact, manager
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