The American journal of managed care
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Physicians respond to pay-for-performance incentives: larger incentives yield greater participation.
To determine the extent to which the size of the available financial incentive influences a physician's decision to participate in a pay-for-performance (P4P) program. ⋯ Our analysis suggests that all stakeholders--health plans, physicians, and patients--would benefit from health plans collaborating on their P4P efforts to maximize physician participation.
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To determine how Medicare benefits affect veterans' use of Veterans Health Administration (VHA) pharmacy services. ⋯ Our findings indicate that non-VHA pharmacy benefits affect both the likelihood and magnitude of VHA pharmacy use. This suggests that Medicare pharmacy coverage (Part D) may significantly reduce the demand for VHA pharmacy services, particularly in geographic regions previously underserved by Medicare managed care plans.
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Percutaneous coronary intervention (PCI) with stenting is increasingly being utilized for acute coronary syndromes (ACS), and the debate over the safety and efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) has intensified. The difficulty in consistently assessing stent safety is because of the widespread off-label use in patients with clinical features and coronary anatomy inconsistent with the approved use in stable patients with relatively noncomplex coronary stenosis, short-term follow-up of only 1 year in pivotal clinical trials that leads to approval, and inconsistency in the nature and duration of adjunctive antiplatelet therapy. Of concern are the high recurrence rates after the first episode of stent thrombosis, as demonstrated by the Dutch Stent Thrombosis Study. ⋯ For patients with non-ST-segment elevation ACS or ST-segment elevation myocardial infarction, dual antiplatelet therapy is recommended for at least 12 months. In summary, more recent data suggest that the benefits outweigh the risks of DESs compared with BMSs, and that the rate of DES placement will continue to rise. It is important that clinicians be aware of the indications for dual antiplatelet therapy and the appropriate durations of dual antiplatelet therapy in patients undergoing PCI.
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Managed care initiatives to reduce cardiovascular disease (CVD) risk have, to date, focused almost exclusively on statins, which are primarily low-density lipoprotein cholesterol-lowering agents and have limited effects on triglycerides and high-density lipoprotein (HDL) cholesterol at commonly used doses. Significant residual CVD risk (ie, risk of recurrent CVD events) remains after treatment with statins and may stem, at least partially, from low HDL cholesterol and/or elevated triglycerides. Consequently, national treatment guidelines suggest that combination therapy may be necessary to address multiple lipid targets and adding niacin or a fibrate to a statin is a strategy to be considered. Recent clinical trial evidence has demonstrated the efficacy of niacin/statin and fenofibric acid/statin combination therapies in treating multiple lipid abnormalities.
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Dual antiplatelet therapy with a thienopyridine in combination with aspirin for 1 to 6 months after stenting has been recommended by the manufacturers to reduce ischemic cardiovascular events and thrombosis after coronary stenting, whereas the current leading guidelines recommend dual antiplatelet therapy for 12 months following percutaneous coronary intervention in all patients not at high risk of bleeding. Despite the established benefits of dual antiplatelet therapy in acute coronary syndrome (ACS) patients, there are concerns regarding the risk of major bleeding. The risks, benefits, and complexity identified in these interventional trials are communicated in this article to enable well-informed therapeutic decisions. ⋯ In addition, adherence to dual antiplatelet therapy is critical but difficult to achieve, and a considerable proportion of patients (1 of 7) discontinue therapy before 30 days of drug-eluting stent implantation. It has been established that premature discontinuation of thienopyridine therapy is associated with a marked increase in the risk of stent thrombosis (and consequently myocardial infarction and/or death) and is the leading independent predictor of stent thrombosis in multivariate analyses. The factors related to premature cessation of thienopyridine therapy are listed with recommendations for minimizing the complications arising as a result of premature discontinuation.