Introduction: Warfarin is the most commonly prescribed drug for stroke prevention among Atrial Fibrillation (AF) patients, especially in older adult populations, but medication nonadherence reduces its effectiveness in clinical practice. Group Based Trajectory Models (GBTM) have been used to identify distinct patterns of adherence behavior related to various medications and understand the patient characteristics associated with each trajectory. The objectives of the study were: 1) Describe trajectories of warfarin adherence among Medicare AF patients, 2) Assess impact of adherence trajectories on AF-related hospitalization, 3) Estimate the AF-related direct costs for each adherence trajectory group. Methods: We identified elderly AF patients initiating warfarin treatment during 2008-2010 using data from a random sample of Medicare beneficiaries. The study’s first aim is to classify patients into different trajectory groups based on their monthly adherence patterns using a Group-Based Trajectory Model (GBTM). A multinomial regression model was used to assess associations between baseline characteristics and adherence trajectories. The second aim is to evaluate the association between adherence trajectories and time to first hospitalization related to stroke or bleeding event. Hospitalization events due to bleeding or stroke were identified using corresponding ICD-9 codes, and a Cox proportional hazard model was performed. The third aim of the study is to calculate AF-related direct medical costs associated with each trajectory group. SASv9.4 was used for analysis. Results: Among 3,246 beneficiaries who met inclusion criteria, six adherence trajectories were identified: 1) rapid-decline non-adherence group (11.5%), 2) moderate non-adherence group (24%), 3) rapid-decline then increasing adherence group (6.8%), 4) moderate-decline non-adherence group (8.2%), 5) slow-decline non-adherence group (24.3%), and 6) perfect adherence group (25.3%). Even though no statistical significances were found in the hazard of hospitalization among the adherence groups, there were higher odds of hospitalization among the lower adherence groups compared to perfect adherence group. Outpatient and monitoring costs were significantly higher in the lower adherence trajectories compared to perfect adherence group. Conclusion:The GBTM is considered an innovative methodological approach that can be applied to longitudinal medication adherence data and account for the dynamic nature of adherence behavior in a better way than traditional adherence measures.

Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Thesis (M. Pharm. (Pharmacy Practice)--North-West University, Potchefstroom Campus, 2009.

Our investigation sought to identify the incidence of treatment failure and its associated costs in patients with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs) treated in the primary care setting. Thirteen clinics participated in this multi-site, observational study. Clinicians consented patients and collected clinical information, pictures, and wound swabs; isolates were processed in the principal investigator's laboratory. Treatment failure was defined as the occurrence of one or more of the following within 90 days: (1) change in antibiotic therapy, (2) subsequent need for incision and drainage, (3) SSTI at new site, (4) SSTI at same site, (5) emergency department visit, or (6) hospitalization. Cost estimates were obtained from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare and Medicaid Service's National Average Drug Acquisition Costs (NADAC). Patients were considered to have “moderate or complicated” SSTIs if they had a lesion ≥ 5cm in diameter, diabetes mellitus, or both. Patients not exhibiting these characteristics were classified as having “mild or uncomplicated” infections. Ninety-eight patients were enrolled. Most patients were of Hispanic ethnicity and more than half of all patients had a body mass index (BMI) ≥ 30kg/m2. The most common treatment modality was incision and drainage (I&D) plus antibiotics (57%). Treatment failure occurred in 21% of all patients at a mean additional cost of $1,933.71. Patients with moderate or complicated SSTIs who received I&D experienced significantly more treatment failures compared mild or uncomplicated patients who received I&D (36% vs. 10%; p = 0.04). The additional cost of treatment failure in patients with moderate or complicated SSTIs was nearly twice that of patients with mild or uncomplicated SSTIs ($2,093.40 vs. $1,255.02; p = 1.0). Treatment failure occurred sooner, on average, in the moderate or complicated group compared to the mild or uncomplicated group (11.8 days vs. 38.8 days; p = 0.06). Among patients with MRSA SSTIs treated in the primary care setting, the rate of treatment failure is high (21%) and costs are considerable ($1,933.71). / text

Introduction: New treatments for stage IV (adv) NSCLC have emerged this past decade. Recent pharmacoeconomic research has focused on cost of treatment, comparative costs of therapies, and cost/cost effectiveness of adding a biologic to traditional therapy. Drug cost is thought to be a primary driver of cost change in NSCLC, yet to our knowledge, characterization of the direct cost of NSCLC has not been published since the new treatments have emerged in the guidelines. Our primary objective was to characterize the direct and segmented cost of adv NSCLC from 2000-9. We also want to determine cost impact of new therapies, and cost trend from 2000-9. Methods: This PharMetrics claims database study includes diagnosed NSCLC patients [greater than or equal to] 20 yo. Small cell lung cancer was excluded. Claims were divided into disease segments and time periods representative of changes in therapy ("pre" (2000-2), "transition" (2003-5), and "current" (2006-9) periods). Descriptive statistics (median, interquartile range (IQR)), chi-square test (nominal data), and Wilcoxan rank sum tests were performed on the data. To adjust for baseline confounders, multivariate least squares regression models were created. Results: Costs are reported as medians in terms of per patient per month (pppm). Overall monthly cost (n=969) was $10,281 pppm. Diagnosis cost $6,601 pppm, active treatment cost $9,287 pppm, and end-of life cost $12,215 pppm. There was no difference in cost between the “transition” (n=439) and “current” (n=503) periods overall or for any segment of disease. Comorbidities had no effect on cost. For patients receiving at least 5 months of active treatment medication (n=316) total median cost was $144,147 per patient ($9,371 pppm). Discussion: There was no difference in cost between the transition and current periods, in regards to either overall cost or segmented cost. The most expensive segment was end-of-life, with a median cost exceeding $12,000 pppm. Surprisingly, comorbidities had no effect on cost. Newer agents (biologics, TKIs, and pemetrexed) represent only a modest portion of cost, with a majority of cost for stage IV NSCLC comprised of non-drug costs. / text

More people living with HIV/AIDS reside in South Africa than any other country in the world, and the nation faces colossal challenges in broadening its response to the now-mature and widespread HIV epidemic (WHO, 2005:1). According to South Africa's Medical Research Council, HIV/AIDS has now become the single largest cause of death in South Africa (Dorrington et a/., 2001:6) and has triggered a prominent transferal in the pattern of mortality from the elderly to the young, particularly among young women (Dorrington, 2001:4). The routine treatment of HIV/AIDS with antiretroviral drugs has transformed HIV-infection from an unvaryingly rapidly terminal illness to a somewhat expensive treatable, chronic disease. Triple therapy or highly active antiretroviral therapy (three-drug combinations of ARVs or HAART) in particular have had paramount impacts on HIV-related morbidity and mortality in settings where these drugs are generally accessible. Objectives of ARV treatment are "maximum, durable suppression of viral load, restoration and/or preservation of immune function, improvement of quality of life and reduction of HIV related morbidity and mortality" (Martinson et a/., 2003:236; Martinez et a/., 2007:251; Hellinger, 2006:1; Kumarasamy, 2004:3). The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that a total of 111 827 South Africans were accessing free antiretroviral treatment in the 200 public health sector facilities across 53 districts and a further 60 000 via the private sector by late December 2005 (UNAIDS, 2005:1). The objective of this study was to review, analyse and interpret the usage and prescribing patterns of antiretroviral drugs in a section of the South African private health care sector for the period 1 January 2005 to 31 December 2006 by utilising a medicine claims database of a pharmacy benefit management company, and to investigate the costs associated with these drugs by performing a quantitative, retrospective drug utilisation review. It was found that the prevalence as well as the total medicine cost of ARV medicine items had increased during the study period but the average number of ARV medicine items per prescription as well as both the average cost per ARV medicine item and the average cost per ARV prescription decreased during the study period. Original innovator ARV medicine items and original ARV medicine items with no generic were found to be relatively expensive in comparison with ARV medicine items in general. Conversely, generic ARV medicine items were ascertained to be relatively inexpensive with reference to ARV medicine items in general. It was perceived that the average cost of ARV medicine items and prescriptions for both genders decreased from 2005 to 2006, while there was an increase in the prevalence of medicine items and prescriptions claimed for both female and male patients. The prevalence and cost of all types of ARV medicine items were found to be higher for female patients in general. It was also established that the prevalence of patients receiving antiretroviral treatment in the private health care sector peaks at the age of >30 to 244 years, in comparison with the lower age of >25 to 239 years in the public health care sector. ARV medicine items claimed for patients in the age group >35 to 239 years represented the highest percentage of the total medicine cost incurred during both study years for all ARV medicine types. The majority of ARV medicine items were prescribed by general medical practitioners, and most ARV medicine items were dispensed by community or private institutional pharmacies. It was determined that combinations of 2NRTI + NNRTI were prescribed with the highest frequency, which is compliant with traditional HAART or 'triple therapy' regimens. Lastly, it was found that none of the top 20 prescriptions for one, two and six ARV medicine items were compliant with the National Antiretroviral Treatment (ART) Guidelines. The majority of the top 20 prescriptions for three ARV medicine items (92.67 per cent during 2005 and 89.94 per cent during 2006) were compliant with the National ART Guidelines. Finally, less than half of the top 20 prescriptions for four ARV medicine items (49.60 per cent during 2005 and 36.11 per cent during 2006) were compliant with the National ART Guidelines. Only 5.56 per cent and 3.92 per cent of the top 16 prescriptions for five ARV medicine items were compliant with the National ART Guidelines during the two study years respectively / Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for systemic control of acute and chronic pain and inflammation (Lin et ah, 2000:1129), but usage problems and side-effects that occur during the post-marketing phase of these drugs are well documented (Thiefin & Beaugerie, 2005:287). Following the demonstration of the value of anti-inflammatory therapy in diseases like rheumatoid arthritis (Boardman & Dudley Hart, 1967:268), new NSAIDs appeared on the market (Dieppe et al., 2004:867), and the indications steadily broadened from inflammatory diseases to almost any painful condition. Studies have indicated that NSAID-associated serious upper gastro-intestinal (GI) adverse events result in 103 000 hospitalisations (Bombardier, 2002:4) and 165 000 deaths per year in the United States. A study in South Africa in 2002 indicated that NSAID utilisation contributed considerably to the total cost of all medicine items from a medicine claim database in the private health care sector (Joubert, 2002:260). The objective of this study was to determine the prevalence and cost of non-steroid anti-inflammatory drugs in a section of the private health care sector, and specifically to determine the prevalence, usage and cost of Coxib (Specific cyclo-oxygenase-2 inhibitor) medicine items before and after the withdrawal of Vioxx® from the market in September 2004 (Merck, 2004). Data from two medicine claim databases for the years 2004, 2005 and 2006 (medicine claim database I) and the years 2005 and 2006 (medicine claim database M), were analysed by means of a retrospective drug utilisation review (DUR) study. The usage of Coxib medicine items was determined, and compared for the periods before and after the withdrawal of Vioxx® in September 2004. It was found that between 9 and 10.5 per cent of prescriptions dispensed through both medicine claim database I and medicine claim database M during the study period were NSAID prescriptions. NSAID medicine items on medicine claim database I represented between 3.9 % (R25 942 986) and 2.9 % (R8 073 034) of the total cost of all medicine items claimed from 2004 to 2006. NSAIDs represented 3.1 % (R58 290 412) and 2.8 % (R57 752 267) of the cost of all medicine items claimed through medicine claim database M during 2005 and 2006 respectively, indicating similar trends in the two medicine claim databases. The prevalence of Coxibs on medicine claim database I decreased from almost 20 % (47 938) in 2004 to 8.4 % (13 276) in 2005, but showed an increase again to 10.9 % (12 355) in 2006. The prevalence of both cyclo-oxygenase (COX) inhibitors, and Coxibs demonstrated a change during 1 September 2004 to 31 December 2004 when COX-inhibitors showed an increase in use, while Coxibs showed and almost equal but opposite trend with a decrease in use. This could possibly be related to perceptions of providers and public with regard to Coxibs and their related safety after the withdrawal of Vioxx® on 30 September 2004 (Merck, 2004) and other Coxibs such as Bextra® (FDA, 2005) in 2005 in USA. It is concluded that most patients who were using Coxibs before the withdrawal of Vioxx®, substituted Coxibs for COX-inhibitors, that are known for their possible gastro-intestinal side-effects. Recommendations for future research regarding NSAID use were also made, and included an investigation of the usage of Coxibs in different age groups, as well as the combination of NSAIDs with gastro-protective medicines in long-term use. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Cancer is a broad term used to describe more than 100 diseases that can affect any part of the body. Cancer is the uncontrollable division of abnormal cells in the human body, which can invade nearby tissue and spread through the bloodstream to other parts of the body (National Cancer Institute, 2007b). Cancer can affect people all over the world, from every race, society and age (Albrecht, 2006:3). The treatment of cancer is becoming more and more expensive as newer and more effective drugs enter the market (Niezen et al., 2006:2887) and diagnosing and screening of cancer patients is showing remarkable progress (Meropol & Schulman, 2007:180). The general objective of this study was to investigate and review the prescribing patterns of antineoplastic and immunomodulating agents in a section of the private health care sector of South Africa. This research can be classified as retrospective and quantitative. Data were obtained from a medicine claims database, of a pharmacy benefit management company. The study population consisted of all prescriptions, containing one or more cancer medicine items (classified according to the ATC classification), for the study period January 2005 to December 2006. Different aspects of cancer were investigated in order to determine the international and national prevalence of cancer and types of cancer and cancer treatment. An overview of managed care aspects were given and through this study it is evident that pharmacoeconomic studies and other managed care aspects could play a major role as information system in the decision making about cancer treatments. The prescribing patterns of antineoplastic and immunomodulating agents were reviewed, analysed and interpreted. It was determined that the number of cancer patients, the number of prescriptions containing one of more cancer drug and the number of cancer medicine items respectively comprised less than 1% of the total number of patients, prescriptions and medicine items recorded on the total database. To the contrary, the total cost of cancer medicine items comprised 4.00% and 5.31% of the total cost of all medicine items (total database) in 2005 and 2006 respectively. This indicates the relatively high cost of cancer medicine items. Almost 50% of all cancer patients are 59 years of age or older and the total cost of cancer medicine items claimed by patients 59 years and older comprised almost 60% of the total cost of all cancer medicine items claimed during the two study years respectively. Cancer medicine items claimed by patients <19 years of age comprised only 2% of all cancer medicine items claimed in both study years and less than 1% of the total cost of all cancer medicine items. Cancer medicine items claimed by patients between the age of 19 and 59 years of age comprised 45.32% and 44.80% of the total number of cancer medicine items in 2005 and 2006 respectively whilst the cost for these age groups comprised 40.81% and 40.73% of the total cost of cancer medicine items. More than 70% of all cancer patients in 2005 and 2006 were females whilst male cancer patients comprised about 30% of all cancer patients. The number of cancer medicine items claimed by female cancer patients also comprised more than 70% of the total number of cancer medicine items claimed in 2005 and 2006, however, the total cost of cancer medicine items was divided almost even between male (45%) and female (55%) cancer patients for both study years. Therefore, according to this study, cancer medicine items claimed by male cancer patients are relatively more expensive than those claimed by female cancer patients. In completion of this study, recommendations for further studies concerning cancer treatment and cost-effective usage of cancer medicine were formulated, including the influence of the nature of the cancer, the age and gender of the patients as well as the treatment costs of cancer. / Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

More people living with HIV/AIDS reside in South Africa than any other country in the world, and the nation faces colossal challenges in broadening its response to the now-mature and widespread HIV epidemic (WHO, 2005:1). According to South Africa's Medical Research Council, HIV/AIDS has now become the single largest cause of death in South Africa (Dorrington et a/., 2001:6) and has triggered a prominent transferal in the pattern of mortality from the elderly to the young, particularly among young women (Dorrington, 2001:4). The routine treatment of HIV/AIDS with antiretroviral drugs has transformed HIV-infection from an unvaryingly rapidly terminal illness to a somewhat expensive treatable, chronic disease. Triple therapy or highly active antiretroviral therapy (three-drug combinations of ARVs or HAART) in particular have had paramount impacts on HIV-related morbidity and mortality in settings where these drugs are generally accessible. Objectives of ARV treatment are "maximum, durable suppression of viral load, restoration and/or preservation of immune function, improvement of quality of life and reduction of HIV related morbidity and mortality" (Martinson et a/., 2003:236; Martinez et a/., 2007:251; Hellinger, 2006:1; Kumarasamy, 2004:3). The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that a total of 111 827 South Africans were accessing free antiretroviral treatment in the 200 public health sector facilities across 53 districts and a further 60 000 via the private sector by late December 2005 (UNAIDS, 2005:1). The objective of this study was to review, analyse and interpret the usage and prescribing patterns of antiretroviral drugs in a section of the South African private health care sector for the period 1 January 2005 to 31 December 2006 by utilising a medicine claims database of a pharmacy benefit management company, and to investigate the costs associated with these drugs by performing a quantitative, retrospective drug utilisation review. It was found that the prevalence as well as the total medicine cost of ARV medicine items had increased during the study period but the average number of ARV medicine items per prescription as well as both the average cost per ARV medicine item and the average cost per ARV prescription decreased during the study period. Original innovator ARV medicine items and original ARV medicine items with no generic were found to be relatively expensive in comparison with ARV medicine items in general. Conversely, generic ARV medicine items were ascertained to be relatively inexpensive with reference to ARV medicine items in general. It was perceived that the average cost of ARV medicine items and prescriptions for both genders decreased from 2005 to 2006, while there was an increase in the prevalence of medicine items and prescriptions claimed for both female and male patients. The prevalence and cost of all types of ARV medicine items were found to be higher for female patients in general. It was also established that the prevalence of patients receiving antiretroviral treatment in the private health care sector peaks at the age of >30 to 244 years, in comparison with the lower age of >25 to 239 years in the public health care sector. ARV medicine items claimed for patients in the age group >35 to 239 years represented the highest percentage of the total medicine cost incurred during both study years for all ARV medicine types. The majority of ARV medicine items were prescribed by general medical practitioners, and most ARV medicine items were dispensed by community or private institutional pharmacies. It was determined that combinations of 2NRTI + NNRTI were prescribed with the highest frequency, which is compliant with traditional HAART or 'triple therapy' regimens. Lastly, it was found that none of the top 20 prescriptions for one, two and six ARV medicine items were compliant with the National Antiretroviral Treatment (ART) Guidelines. The majority of the top 20 prescriptions for three ARV medicine items (92.67 per cent during 2005 and 89.94 per cent during 2006) were compliant with the National ART Guidelines. Finally, less than half of the top 20 prescriptions for four ARV medicine items (49.60 per cent during 2005 and 36.11 per cent during 2006) were compliant with the National ART Guidelines. Only 5.56 per cent and 3.92 per cent of the top 16 prescriptions for five ARV medicine items were compliant with the National ART Guidelines during the two study years respectively / Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for systemic control of acute and chronic pain and inflammation (Lin et ah, 2000:1129), but usage problems and side-effects that occur during the post-marketing phase of these drugs are well documented (Thiefin & Beaugerie, 2005:287). Following the demonstration of the value of anti-inflammatory therapy in diseases like rheumatoid arthritis (Boardman & Dudley Hart, 1967:268), new NSAIDs appeared on the market (Dieppe et al., 2004:867), and the indications steadily broadened from inflammatory diseases to almost any painful condition. Studies have indicated that NSAID-associated serious upper gastro-intestinal (GI) adverse events result in 103 000 hospitalisations (Bombardier, 2002:4) and 165 000 deaths per year in the United States. A study in South Africa in 2002 indicated that NSAID utilisation contributed considerably to the total cost of all medicine items from a medicine claim database in the private health care sector (Joubert, 2002:260). The objective of this study was to determine the prevalence and cost of non-steroid anti-inflammatory drugs in a section of the private health care sector, and specifically to determine the prevalence, usage and cost of Coxib (Specific cyclo-oxygenase-2 inhibitor) medicine items before and after the withdrawal of Vioxx® from the market in September 2004 (Merck, 2004). Data from two medicine claim databases for the years 2004, 2005 and 2006 (medicine claim database I) and the years 2005 and 2006 (medicine claim database M), were analysed by means of a retrospective drug utilisation review (DUR) study. The usage of Coxib medicine items was determined, and compared for the periods before and after the withdrawal of Vioxx® in September 2004. It was found that between 9 and 10.5 per cent of prescriptions dispensed through both medicine claim database I and medicine claim database M during the study period were NSAID prescriptions. NSAID medicine items on medicine claim database I represented between 3.9 % (R25 942 986) and 2.9 % (R8 073 034) of the total cost of all medicine items claimed from 2004 to 2006. NSAIDs represented 3.1 % (R58 290 412) and 2.8 % (R57 752 267) of the cost of all medicine items claimed through medicine claim database M during 2005 and 2006 respectively, indicating similar trends in the two medicine claim databases. The prevalence of Coxibs on medicine claim database I decreased from almost 20 % (47 938) in 2004 to 8.4 % (13 276) in 2005, but showed an increase again to 10.9 % (12 355) in 2006. The prevalence of both cyclo-oxygenase (COX) inhibitors, and Coxibs demonstrated a change during 1 September 2004 to 31 December 2004 when COX-inhibitors showed an increase in use, while Coxibs showed and almost equal but opposite trend with a decrease in use. This could possibly be related to perceptions of providers and public with regard to Coxibs and their related safety after the withdrawal of Vioxx® on 30 September 2004 (Merck, 2004) and other Coxibs such as Bextra® (FDA, 2005) in 2005 in USA. It is concluded that most patients who were using Coxibs before the withdrawal of Vioxx®, substituted Coxibs for COX-inhibitors, that are known for their possible gastro-intestinal side-effects. Recommendations for future research regarding NSAID use were also made, and included an investigation of the usage of Coxibs in different age groups, as well as the combination of NSAIDs with gastro-protective medicines in long-term use. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.