Springer Science and Business Media LLC

Acute repetitive seizures, more commonly known as cluster, crescendo or sequential seizures, are defined as episodes of increased seizure activity occurring in patients with refractory epilepsy who are already receiving stable regimens of anticonvulsants. They lie in the seizure spectrum between isolated seizures and status epilepticus. If acute repetitive seizures are left untreated, they may progress to status epilepticus. Acute repetitive seizures and prolonged seizures are rated as a neurological emergency and treatment must be prompt. The primary goals of therapy are cessation of the seizure and prevention of recurrence. The use of traditional intravenous agents such as phenytoin, phenobarbital (phenobarbitone), lorazepam and diazepam is well established in the first-line treatment of acute seizures. However, adverse effects and the time to onset of effect often dictate the choice between older anticonvulsants. Newer agents (such as fosphenytoin) and alternative routes of administration (such as rectal administration of diazepam solution) have been developed in an effort to reduce adverse effects, decrease the time to onset of effect, reduce acute care facility costs and investigate the possibility of home treatment. Diazepam rectal gel, a newer formulation of diazepam intended for rectal administration, effectively terminates acute seizures and prevents recurrence within the first 12 hours after administration. Diazepam rectal gel is available for use by a trained caregiver in a home setting and, therefore, emergency room treatment and hospitalisation may not be required and could be avoided. This may result in reductions in financial and emotional costs associated with acute repetitive seizures, but broader clinical experience is needed to assess this. Diazepam rectal gel is not associated with respiratory depression and most adverse effects appear to be mild to moderate in severity. At present, diazepam rectal gel is a valuable addition to the current anticonvulsant armamentarium for first-line therapy of acute repetitive seizures. Wider clinical experience will better determine the place of this formulation in the treatment of this debilitating disorder.

Disease management has gained popularity as a way to improve health status and control of chronic illness through the use of risk stratification, targeted nurse outreach, telephonic nurse advice, and evidence-based guidelines in managing illness. Disease management programs have been successfully implemented by commercial insurers and managed care plans, as well as in Medicare and state Medicaid programs. Although evidence regarding cost savings is inconsistent, it appears that disease management programs do impact health status and quality of care, and improve self-management among the chronically ill. Disease management programs can be customized to meet the needs of vulnerable subpopulations. This article explores the barriers to dealing with chronic illness and other factors faced by disease management programs for Medicaid populations. Barriers to participation and success in disease management for Medicaid beneficiaries are apparent due to lack of access to translation and interpretation services; difficulty with community outreach; achieving buy in from providers and beneficiaries; problems with housing; difficulties accessing primary and specialty care; problems with the availability of pharmacy, durable medical equipment, and other support services; as well as difficulties with Medicaid eligibility and ‘churn’. In order to create a successful disease management program that positively impacts health status, utilization, and cost, it is necessary to consider all of these barriers when designing an intervention for Medicaid beneficiaries. Some of the innovative ways to handle the difficulties of dealing with Medicaid or other low-income populations with special healthcare needs include expanded interpretation and translation activities, extensive community outreach to patients and safety net providers such as clinics and public hospitals, providing support services related to non-medical problems experienced by enrollees, providing understandable written and verbal instructions and training related to health education and medication adherence, as well as efforts to track and maintain contact with eligible and enrolled individuals. Disease management programs can be successful in saving money and improving health in Medicaid populations. However, they must be carefully designed with the specific state Medicaid program and should target the needs of the state’s beneficiaries.

The US disease management (DM) industry continues to endorse the use of the methodologically flawed pre-post design to evaluate financial outcomes, which regularly reports returns on investment of up to 8:1. This is in sharp contrast to the peer-reviewed literature and large Medicare demonstration projects that generally report little, if any, cost savings from DM. The industry defends the practice of using the pre-post evaluation design by suggesting that measuring total healthcare costs at the diseased-population level eliminates regression to the mean and accounts for indirect changes in physician behavior. The industry further argues that equivalent and concurrent control groups are not available and that instead, a cost trend of the non-diseased population should be used to provide equivalence. This article illustrates the fallacies of these arguments and demonstrates how the pre-post technique elicits financial results generally favoring the DM program. Given that the continued use and support of this methodology serves only to propagate the concerns over the financial value of DM, it is time that a collective decision be made as to whether maximizing short-term profits is worth jeopardizing the long-term viability of the entire industry. Additionally as important, other healthcare systems around the world are looking to the US DM industry for guidance as they ponder the introduction of DM in their own countries. The inability of DM to accurately measure and achieve financial savings may be inhibiting the widespread initiation of future DM programs.

Prescription drugs are a significant and rising component of healthcare costs. To limit this expenditure and maximize cost savings, half of the pay-for-performance health programs in the US reward generic drug prescribing once the patents on brand-name drugs expire. This article discusses arguments for and against the rate of generic drug prescribing as a fair measure for pay for performance from both provider and patient perspectives. Compared with brand-name drugs, generic drugs are usually cheaper to purchase, can avoid confusion over different names for the same drug, minimize commercial influences from drug manufacturers, and can allow pharmacists to dispense any medicine that meets the necessary specifications. However, saving money may be a responsibility of governments and payers rather than providers. Some providers and patients are uneasy that financial incentives for generic prescribing may not directly aim to improve patient care and may motivate providers to put their own financial interests above the welfare of patients. It has not been proven that the financial incentives are large enough to change prescribing behavior or that generic drugs are less safe or less effective than their brand-name counterparts. However, there are legitimate concerns around bioequivalence standards, and some providers and patients object to attempts to compromise their autonomy. High-quality care requires not a rigid adherence to performance indicators but a careful and flexible balancing of provider and patient interests. A final concern is patient non-adherence or mistakes in adherence following a change to a generic drug. It is uncertain that pay for performance is the best way — or a fair way — to contain spiraling health costs.

Depressive symptoms are extremely common in the general population and, particularly, in the medically ill. The diagnostic criteria for a major depressive disorder set a clinical threshold for the forms of depression requiring specific treatment. However, the criteria require a specialised psychiatric interview and are difficult to use outside of psychiatry. For screening purposes, self-rating questionnaires have been proposed, but none have appeared to be completely satisfactory. There is much evidence that depression in the medically ill is frequently unrecognised and untreated. The diagnostic criteria for major depression are the essential tools for case identification and inclusion in studies (particularly if involving experiments in therapeutics, such as drug trials). However, they do not provide an adequate threshold for intensity of symptoms and, in some cases, should be supplemented by other instruments. It is only in recent years that it has become apparent that, despite effective treatments, the longer term outcome in depression is still problematic. Current treatment protocols appear to be largely inadequate in relapse prevention. Screening for depressive relapse and subclinical symptomatology that entails considerable prognostic value thus becomes of considerable value. Such screening requires a conceptual shift from current oversimplified views on assessment and course of depressive episodes based on psychometric principles to multimodal, clinically derived approaches according to clinimetric principles. Depression appears to be more and more a potentially chronic and greatly invalidating disease that represents a major challenge to modern healthcare.

Pain assessment and control have received increasing attention as a quality issue in medicine. However, pain has rarely been addressed as a cost-containment issue. We performed a single-center retrospective analysis of information abstracted from the medical records of 1445 adult patients who were treated in family medicine clinics and referred to specialists in Rochester, Minnesota, USA. Patients were categorized into frequent utilizers of physician visits and others, with those having more than eight medical visits in the previous 6 months being classified as frequent users. General pain was self-assessed using a 10-point scale. Multiple logistic regression analysis was used to test the relationship between pain and the frequency of visits, after adjustment for co-morbidities, body mass index (BMI), and demographic characteristics. Findings revealed that patients with pain scores ≥7 had higher odds of being frequent visitors after adjusting for co-morbidity, BMI, age, marital status, and gender (adjusted odds ratio [AOR] = 1.60; 95% CI 1.12, 2.28; p < 0.01). AORs for being a frequent user were significantly greater for patients with ‘moderate’ Charlson co-morbidity scores (AOR = 2.83; 95% CI 2.03, 3.95; p < 0.01) than for those with no co-morbid diseases. They were also lower for men than for women (AOR = 0.71; 95% CI 0.54, 0.94; p = 0.02), but higher for unmarried persons than for married persons (AOR = 1.72; 95% CI 1.28, 2.32; p < 0.01). Severe pain is associated with being a more frequent user of medical services.

Bipolar disorder is a chronic relapsing remitting illness affecting 1–2% of the general adult population. Awareness of the limitations of pharmacological treatment for this disorder has encouraged the development of psychological treatments and a large body of evidence now exists demonstrating the effectiveness of several types of psychosocial interventions in the treatment and prevention of relapse for bipolar disorder. Unfortunately, it is difficult for many individuals with bipolar disorder to access such programs due to financial constraints and restricted roll-out. One solution to this difficulty is to use Internet-based delivery of targeted psychoeducation, cognitive behavior management and online medication monitoring to improve relapse prevention for those with bipolar disorder. The focus of this article is to discuss the aims and methodology of this unique, collaborative randomized control trial that evaluates the effectiveness of an Internet-based disease management program (termed Recovery Road [RR]). The RR program incorporates both symptom monitoring with feedback, and targeted psychosocial treatment for adults with bipolar disorder delivered over a 12-month period. The overall aim was to determine whether this web-based adjunctive relapse prevention program can improve mental health outcomes. Upon successful enrolment, participants were automatically randomized into either the intervention (RR) or control group. The control group received some relevant information but did not include program components considered to be active parts of the experimental intervention. This article also describes a recruitment, enrolment and randomization process that maximizes the potential of the Internet for research and data collection purposes. At the time of writing full results were not yet available and, thus, were not reported in this article. Interim outcomes indicate that the online enrolment has been successful and participants are making full use of all online features of the active program included by the support facility. The difficulties with maintaining individuals on the control program are described and samples of typical anecdotal comments provided by participants to the research group via the support facility are presented.