A recent study (DY Graham, A Tansel. Clin Gastroenterol Hepatol 2018; 16: 800-808) analyzed 56 randomized trials to determine relative potency of proton pump inhibitors (PPIs) based on time in which intragastric pH was 4 or less (pH4time).
Pantoprazole 20 mg was equivalent to 4.5 mg of omeprazole
Lansoprazole 15 mg was equivalent to 13.5 mg of omeprazole
Esomeprazole 20 mg was equivalent to 32 mg of omeprazole
Rabeprazole 20 mg was equivalent to 36 mg of omeprazole
The authors note that peak effectiveness for PPIs was at ‘approximately 70 mg of omeprazole equivalents’. In addition, they state that twice a day dosing was more effective than increasing once a day dosing; however, three times a day dosing was not more effective than twice a day. “Dexlansoprazole, a quasi-twice-a-day formulation produced similar acid suppression to the lowest twice-daily PPI regimen and 20 mg vonoprazan once daily provided similar efficacy aas high-dose twice-daily PPI.” The authors also compare costs; generics of pantoprazole, omeprazole, and esomeprazole cost as little as $0.02-0.04 per omeprazole equivalent. Thus, 20 mg of omeprazole would be as little as 40 cents.
My take: Using the lowest effective dose of a PPI is recommended. In patients needing higher dosing or with suboptimal response to acid suppression, this data can be very helpful.
The average biologic-taking patient accounted for $25 275 PMPY in 2007 and $36 051 PMPY in 2015. The average paediatric biologic-taking patient accounted for $23 616 PMPY in 2007 and $41 109 PMPY in 2015. In all patients, the share of costs for biologics increased from 72.9% in 2007 to 85.7% in 2015 (81.7% in 2007 to 94.9% in 2015 in paediatrics).
The vast majority of costs allocated to out-patient IBD medications in the USA is attributed to increasing use of biologic therapies despite the relative minority of biologic-taking patients.
My take: Biologic therapies are costly but also very effective.
Two articles highlight the upside and downside of retail clinics.
Iglehart JK. NEJM 2015; 301-3
Chang JE et al. NEJM 2015; 382-8
Currently, there are ~1900 retail clinics with four main ‘players:’ CVS, Walgreens, Kroger, and Target. However, Target has recently made a deal with CVS and Walmart is expanding into retail clinics as well. Almost all of these clinics accept private insurance and medicare; growing numbers accept medicaid too.
Retail clinics offer a limited scope of care and typically are staffed by midlevel providers (nurse practitioners or physician assistants). In contrast, urgent cares offer more complex services and typically are staffed by physicians.
For consumers, the key advantages of retail clinics: lower costs with transparent pricing, convenience due to extended hours and locations, and often short wait times.
Potential disruption in longitudinal care (“medical home”)
What about quality?
“Research has not found that retail clinics deliver poor quality care, overprescribe antibiotics, or adversely impact delivery of preventive care.”
Do Retail Clinics Enhance Access?
Yes but these clinics are disproportionately located in areas with relatively high income. Nevertheless, “approximately 61% of retail-clinic visits and 37% of urgent care visits involve patients without a primary care provider.”
“One study …showed that patients did properly self-triage, with more than 88% of retail-clinic episodes resolved in one visit. Another study showed that 2.3% of retail-clinic patients were triaged to an emergency department or physician’s office.”
Why Would Physicians Oppose These Retail Clinics?
While primary care organizations have raised concerns about quality and continuity of care, a basic economic issue is likely at work as well. “The current reimbursement system renders simple acute health problems high-margin work that can offset losses from treating more complex problems.“
Bottomline: Retail clinics are filling a need for many patients in terms of cost and convenience for simple acute problems.
With the arrival of newer expensive hepatitis C virus (HCV) therapies, there has been an effort to prove that the costs are within reason. One study (Hepatology 2014; 60: 1187-95) looking at this issue examines the cost of a sustained virological response (SVR) with the previous best therapy: Telaprevir-Based Triple Therapy.
Design: Records from 147 patients who received telaprevir-based triple therapy in 2011 were reviewed.
According to the authors (supported by Gilead Sciences), median cost of care was $83,721 per patient and the median cost per SVR was $189,338. The costs of two of the drugs, telaprevir and pegylated interferon, accounted for 85% of the total costs. Other costs included adverse management (8%), ribavirin (4%), professional fees (2%), and laboratory fees (1%).
The main reason besides pharmaceutical prices for the high costs were the SVR rate of 44%.
Bottomline: If a patient requires HCV therapy, the newer, more effective, expensive agents are likely to compare favorably with the less new, less effective, expensive medications.
Also noted: Hepatology 2014; 60: 1211-21. “WELCOME” Study tested whether 15-18 months of docosahexaenoic acid (DHA) plus eicosapentaenoic acid (EPA) decreased liver fat and histology in nonalcoholic fatty liver disease (NAFLD). n=101, with 51 in treatment group. Findings the DHA+EPA had a “trend toward improvement in liver fat” percentage but no improvement in fibrosis.