Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.

Patients with an IBS diagnosis represent a substantial cost to managed care before and after the diagnosis of IBS. Costs associated with these patients result mainly from non-IBS conditions. Further research is warranted to identify these patients earlier, and to prevent the economic burden associated with them.

We attempted to determine the economic impact of three alternatives for the treatment of chlamydial infections in the emergency department: a written prescription for 7 days of doxycycline therapy (D-RX); a prepacked 7-day supply of doxycycline (D-ED); or a single 1-g dose of azithromycin (AZI). Data inputs for the model were obtained from both patient experience and literature sources. Primary health outcomes of the model were number of infection relapses. Economic outcomes were costs for initial treatment, treatment of relapses, and treatment of complications of relapse. For every 1000 patients, D-ED and AZI resulted in 21.6 (-10 to -41) and 36.2 (-25 to -63) fewer relapses than D-RX, respectively; AZI resulted in 14.6 (-35 to -4) fewer relapses than D-ED. Total costs were decreased for D-ED and AZI versus D-RX by $18,879 (-$39,000 to -$8000) and $24,039 (-$59,000 to -$10,000), respectively, and AZI resulted in a total cost decrease of $5160 (-$35,000 to +$6000) versus D-ED. Both D-ER and AZI decreased infection relapses and overall health care costs compared with D-RX. Also, AZI resulted in additional decreases in relapses versus D-ED, although the incremental impact on cost was inconclusive.

Practice guidelines and clinical pathways are increasingly being used as tools to enhance the quality of health care services and to manage costs better. This article reviews the role of guidelines and clinical pathways in health care as defined within the broader concept of practice policies. The factors that increase the effectiveness of practice policies are examined. These include the origin of development, dissemination technique, and implementation strategy. Policies that are internally developed and implemented with concurrent reminder systems are the most effective. Clinical pathways fit these criteria and are therefore highly effective policy types. The roles that pharmacists within health systems can undertake in policy development are described. These include writing the policy document, providing expert review, providing education, and most important, facilitating the desired outcomes by implementing pharmacy services that promote compliance with the guidelines. Examples of pharmacy-based guideline and pathway implementation from the Henry Ford Health System are described for inpatient anticoagulation, outpatient preferred drug formulary policy, and outpatient lipid therapy management.

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