Biomedical subjects

Rajesh Balkrishnan

Publications and source records attributed to Rajesh Balkrishnan.

At least 37 records · Page 2Linked to original sources

PubMed2006

Predictors of treatment choices and associated outcomes in actinic keratoses: results from a national physician survey study.

OBJECTIVES: Actinic keratoses (AKs) are common skin lesions with the potential to progress to squamous cell carcinoma. Many effective treatment alternatives exist, yet the reasons for treatment choice have not been explored. This study examined which AK therapy was preferred among dermatologists and primary care physicians (PCPs), as well as potential determinants of therapeutic selection. METHODS: A random national sample of 534 dermatologists and PCPs selected from the American Medical Association database completed AK questionnaires. The final sample included 1184 AK patients treated by dermatologists and 559 AK patients treated and/or referred by PCPs. All analyses were weighted using the survey sampling weights. RESULTS: Patients who had new and recurring lesions as well as patients who had a mean duration of more than a year since the last AK episode treatment (all p<0.05) were more likely to receive pharmacotherapy. Patients being treated by a dermatologist, receiving pharmacotherapy treatment only, and having both new and recurring lesions (all p<0.05) were less likely to have a complete treatment success. CONCLUSIONS: This study identifies several patient and physician factors associated with treatment preference and related outcomes in patients being treated for AK.

Aged↗

PubMed2006

Trends in on and off-label calcipotriene use.

Following its introduction in 1994, calcipotriene quickly became the single most prescribed medication for psoriasis according to National Ambulatory Medical Care Survey (NAMCS) data. Primarily through regulation of cellular differentiation, calcipotriene may be effective in dermatoses other than psoriasis. We characterize the clinical trends in the utilization of calcipotriene by analyzing a representative sample of visits to US physicians. Demographic characteristics, specialty of the provider, and off-label uses are reported. Calcipotriene was mentioned at 5.8 million of all NAMCS visits during the study period. Nearly 57% of mentions of calcipotriene were not linked to a diagnosis of psoriasis. Adjusted use for gender and race were relatively stable; there was a rise in non-psoriasis uses and use among non-dermatologists in 1997. Our findings support previous reports of the utility of calcipotriene in treating other dermatoses as witnessed by the numerous conditions for which its use was observed. Physicians and policy-makers should be aware of the role that this medication plays in the delivery of dermatologic care.

Calcitriol↗

PubMed2006

Death from psoriasis: representative US data.

OBJECTIVES: Psoriasis can be associated with severe, life-threatening exacerbations. We sought to approximate the mortality associated with hospitalizations for psoriasis. MATERIALS AND METHODS: We analyzed data from two sources to estimate a death rate associated with psoriasis. RESULTS: There were 471 hospital admissions for psoriasis from 1988 to 2001 with a corresponding mortality rate of 1.5%. Documented on nationwide death certificates, there were a total of 29, 33, and 25 deaths attributable to psoriasis in 2001, 2000, and 1999, respectively. CONCLUSIONS: Though effective therapies for severe psoriasis are available, access to them is not guaranteed. It is disturbing to think that the deaths observed here could, at least in part, be prevented with the appropriate use of treatments.

Adult↗

PubMed2006

Critical factors determining the potency of topical corticosteroids.

The vasoconstrictor assay is a highly reliable method used to determine the bioequivalence of topical corticosteroid preparations. By assessing skin blanching, the assay describes the delivery of the active agent through the skin barrier, intrinsic activity at the receptor, and the rate of clearance from the site of application. Vasoconstrictor rankings are generally good predictors of efficacy in clinical trials. Vasoconstrictor assays are not as predictive of outcomes in clinical practice because these assays do not account for a critical factor: how well patients use the medication. Patient compliance plays a vital role in corticosteroid potency.

Administration, Cutaneous↗

PubMed2006

How much of a topical agent should be prescribed for children of different sizes?

BACKGROUND: Compared with guidelines for the quantity of topical corticosteroids to apply in adults, standards for the use of topical corticosteroids in children are not well described. OBJECTIVE: To devise simple-to-use guidelines for topical corticosteroid quantities needed in infants, children, pre-teens, and adults. METHODS: We determined body surface area (BSA) using mean heights and weights in order to calculate the appropriate quantities of medication to be prescribed. RESULTS: As a rough estimate, infants require one-fifth of adult doses, children two-fifths of adult doses, and adolescents two-thirds of adult doses. However, the assessment of BSA may vary considerably between clinicians. Patients may also vary in how thickly they apply topical medication. CONCLUSIONS: A simple guideline for how much topical corticosteroid to prescribe may facilitate the treatment of young children with skin disease.

Administration, Topical↗

PubMed2006

Adverse events from systemic therapies for psoriasis are common in clinical practice.

BACKGROUND: Patients with moderate-to-severe psoriasis frequently require systemic treatment and these medications may be associated with adverse effects. Little is known about the frequency of these events when systemic agents are used in true clinical practice. OBJECTIVE: To determine the frequency of adverse events associated with various systemic psoriasis therapies. METHODS: A retrospective chart review of 753 patients treated in an academic dermatology practice was performed to identify the frequency of adverse events. Poisson regression was used to estimate the odds of significant events for each systemic therapy; UVB-treated patients served as a control population. RESULTS: Methotrexate seemed to be the most prescribed medication. Adverse events were noted with all forms of systemic psoriasis therapy. The highest event rate was seen with oral retinoids, though most of these were considered minor (64%). Cyclosporine had the highest significant adverse event rate (0.9 events/patient). For 'significant' adverse events, oral agents had an adjusted odds ratio>6 compared to standard UVB therapy. The highest risk was for cyclosporine (OR = 20.3); however, the estimate was imprecise (95% confidence interval [4.3, 96.6]). CONCLUSIONS: Traditional psoriasis therapies are associated with significant adverse events in some patients despite toxicity-sparing approaches such as combination therapy. Clinicians need to be aware of screening for adverse events in order to best ensure the safety of their patients and to maximize the efficacy of a given agent. There is still a need for the development of safe and effective treatments for patients with moderate-to-severe psoriasis.

Adult↗

PubMed2006

Medication adherence and health care costs associated with biologics in Medicaid-enrolled patients with psoriasis.

BACKGROUND: Costs and patients' adherence related to biologics are important factors to consider while making informed decisions regarding therapy with biologics in psoriasis management. OBJECTIVE: To examine predictors of adherence related to biologics, total health care costs, and service utilization among psoriasis patients. METHODS: This was a longitudinal cohort study of psoriasis patients (<65 years old) enrolled in North Carolina Medicaid who were prescribed biologics (alefacept, efalizumab, and etanercept). Patients' medication adherence, health care costs, and service utilization patterns in the pre- and post-biologics period were examined. RESULTS: Adherence to biologics was significantly higher compared with the other psoriasis medications (0.66 vs 0.39; p<0.001). Prescription costs were significantly higher in the post-biologics period (3796.77 US dollars vs 11,706.32 US dollars; p<0.001). However, total health care costs in the post-biologics period did not differ significantly from the pre-biologics period (14,662.22 US dollars vs 16,156.10 US dollars; p>0.05). Patients' adherence and health care costs did not differ significantly across the biologics. After controlling for other variables, patients had a significantly lower number of hospitalizations in the post-biologics period (p<0.001). CONCLUSIONS: Although costs associated with prescriptions for biologics were higher, total health care costs did not differ significantly in the post-biologics period. Biologics had a better adherence rate compared with other psoriasis medications.

Adult↗

PubMed2006

Correlates of health-related quality of life in women with severe facial blemishes.

BACKGROUND: Facial appearance plays a large role in self-perception and interaction with others. Visible facial skin lesions are a common condition. Purpose This study assessed factors associated with health-related quality of life (HRQOL) in women with visible facial skin lesions. METHODS: The study included 73 women with one or more of the following conditions: acne, dermatosis papulosis, hypopigmentation, lentigenes, melasma, rosacea, vascular proliferations and other facial scars. The Skindex-16 was used as a measure of HRQOL. Fear of negative evaluation (FNE) was assessed to determine whether self-perception characteristics relate to HRQOL. RESULTS: There were strong correlations in both bivariate and multivariate analyses among increased FNE, heightened perception of QOL without the facial condition and lower overall HRQOL (P< 0.05 and P< 0.01, respectively). There were no differences in HRQOL by type of facial condition, as well as no effects of the area covered by the condition on HRQOL. Interestingly, women not using foundations represented only 10% of the study population and had better HRQOL than women who did use foundations. CONCLUSIONS: Severe facial blemishes of any cause have a significant impact on women's QOL, and the effect of these lesions is mediated in part by psychological characteristics related to self-perception and self-presentation.

Adolescent↗

PubMed2006

Psoriasis treatment in the United States at the end of the 20th century.

BACKGROUND: Psoriasis presents many management complexities. A cornerstone of therapy has been topical corticosteroids, although over the past 10 years there have been many additions to the medication armamentarium. Furthermore, various combination regimens and approaches have been advocated. OBJECTIVE: We sought to characterize various patterns of psoriasis health care delivery and the changes associated with these patterns from 1990 to 2001. METHODS: Visits for psoriasis were identified using National Ambulatory Medical Care survey data, a representative survey of visits to physician offices in the United States. We determined basic demographic characteristics, specialty of the physician provider and medications listed at these visits over the 1990-2001 interval. RESULTS: There were more than 13.5 million visits for psoriasis during the 12-year study period. Dermatologists were responsible for the majority of the visits over the study interval (82%) although there was an overall decline in the proportion of psoriasis visits to dermatologists. As a category, the most common medications used for psoriasis were topical steroids. Topical calcipotriene was the single-most listed medication. There was no observed use of non-corticosteroid topical agents at visits to non-dermatologists. Non-dermatologists were as likely as dermatologists to list a systemic medication at a visit as well as use a systemic as monotherapy. DISCUSSION: In conclusion, the primary topical therapies for psoriasis remain clobetasol and calcipotriene. The decreasing role of dermatologists in the treatment of psoriasis is probably a complex issue, but may relate in part to the difficulty of obtaining access to dermatology care.

Administration, Topical↗

PubMed2006

Nonmelanoma skin cancer: is the incidence really increasing among patients younger than 40? A reexamination using 25 years of U.S. outpatient data.

OBJECTIVE: An increasing incidence of basal cell carcinomas and squamous cell carcinomas in patients younger than 40 years old diagnosed during years 1973 to 2003 was found in a recent population-based study in Olmsted County, Minnesota. We performed additional analyses using nationally representative patient samples to confirm these trends. STUDY DESIGN: We analyzed a cross-sectional survey data on outpatient diagnoses, the National Ambulatory Medical Care Survey data from 1979 to 2003, for melanoma skin cancer. RESULTS: A total of 4,100 office visits for nonmelanoma skin cancers were recorded, including 230 in patients younger than 40. Multivariate analysis indicated no significant increase in the number of office visits related to nonmelanoma skin cancer in younger patients [odds ratio (OR), 2.77; 95% CI, 0.75-10.26]. The mean age of office visits for nonmelanoma skin cancer did not change significantly. The ages of the office visit patients were 64.7 years and 69.02 years in the years 1979 and 2003, respectively. CONCLUSIONS: Based on a representative sample of outpatient visit diagnoses, visits are not increasing for nonmelanoma skin cancer among patients 40 years and younger in the United States, albeit direct measurement of tumor incidence was not possible with this database.

Adult↗

PubMed2006

The utility of a data-logging device for measuring adherence to home phototherapy.

BACKGROUND: Treatment adherence to home phototherapy is not well characterized. PURPOSE: To develop an accurate measure of home phototherapy unit usage. METHODS: We tested a commercially available data logger containing a photo-sensor on two home phototherapy units. RESULTS: The data logger accurately recorded actual usage and did not record stray light sources over the study period. CONCLUSION: A data logger can accurately capture usage patterns for a home phototherapy unit. These devices could potentially be used in clinical trials to measure adherence to home phototherapy treatment regimens.

Electronic Data Processing↗

PubMed2006

Outcomes associated with introduction of thiazolidinedione therapy in Medicaid enrolled patients with type 2 diabetes: an updated and expanded retrospective analysis.

OBJECTIVES: In an earlier analysis, differences in health-care costs, medication adherence, and persistence were examined between patients with type 2 diabetes, enrolled in the North Carolina Medicaid, who had newly started thiazolidinedione (TZD) therapy and those starting other oral antidiabetic agents. In this analysis, the size of the cohort was increased by including 18 months of additional Medicaid data (until December 2004) and sought to: (1) replicate the results of the original study in a larger cohort; and (2) extend the original analysis by providing an additional 18 months of observational follow-up. METHODS: A total of 2660 patients newly starting TZD therapy between July 2001 and December 2003 were compared to 2050 patients starting other oral antidiabetic medication for health-care costs and outcomes in the post-medication start year. In addition, the initial cohort was followed for an additional 18 months to examine if there were any differences in outcomes, such as hospitalization and total health-care costs, that could be associated with the type of therapy. Multivariate regression techniques, incorporating health-care utilization in the year prior to start of new therapy, were used to determine the net cost impact of one therapy versus the other. RESULTS: Multiple regression analyses found that patients starting TZD have better treatment persistence in the post-medication start year compared to patients starting other oral antidiabetic agents (4% increase in therapy persistence index, p < 0.001). In addition, patients starting TZDs had 18.9% lower total annual health-care costs (p < 0.01) compared to patients starting other oral antidiabetic agents. Examination of the original cohort of 3191 patients, for up to an additional 18 months, showed TZD's association with improved adherence rates but not with persistence. Importantly, treatment adherence remained the strongest independent predictor of decreased hospitalization risk and health-care cost reduction in this population. CONCLUSIONS: Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly greater treatment adherence, in the post-start year, compared to patients starting other oral antidiabetic agents.

Administration, Oral↗

PubMed2006

Home ultraviolet B phototherapy: a cost-effective option for severe psoriasis.

The cost of treating severe psoriasis has risen dramatically, and treatment options vary widely in terms of cost and efficacy. However, little information is available on the relative costs of home phototherapy and other long-term management options, specifically in the context of managed care. A payer-perspective cost model was developed to estimate and compare the direct expenditures associated with a 30-year course of various treatments for severe psoriasis. Within two years of treatment initiation, home-administered ultraviolet B phototherapy was less costly than any of the other treatments examined, including methotrexate, psoralen plus ultraviolet A, the retinoid acitretin, and new biologic agents. In addition, the efficacy and safety profile of home ultraviolet B phototherapy make it an excellent choice for extended management.

Acute Disease↗

PubMed2006

Predictors of healthcare outcomes and costs related to medication use in patients with acne in the United States.

This study investigated the relationship among health status, costs linked with the treatment of acne in the United States, and other aspects related to medication use. The US Medical Expenditure Panel Survey (MEPS) database was analyzed for a cohort of people with acne. This cross-sectional study obtained costs, demographics, healthcare service utilization, and clinical patient variables from the MEPS database. The EuroQol Group's EQ-5D scores available in MEPS were used for health status information. Multivariate weighted analysis was performed for data for approximately 5 million patients (weighted sample size). Nearly 70% of the patients used some type of medication for acne. Acne-related medication accounted for approximately 36% of the total acne-related annual healthcare costs, with an average of 2 annual acne prescription refills per patient. Increased number of refills of acne-related medications was associated with an improvement in health status (P<.05). Increased physician office-based visits were the only predictors of higher acne-related annual healthcare costs (P<.01). Adherence to acne medications is an important component of better health status. Pharmacologic treatment of acne does not significantly add to acne-related annual healthcare costs.

Acne Vulgaris↗

PubMed2006

Clobetasol propionate for psoriasis: are ointments really more potent?

BACKGROUND: Clobetasol propionate is the most common topical therapy used for psoriasis in the US. Conventional dermatologic wisdom is that ointment preparations provide the highest potency (due to their occlusive nature and moisturizing ability) and are best suited for psoriasis. However, patients often find application of ointment to be messy, raising concerns about both short-term and long-term adherence to treatment. This article reviews the current literature and assesses the relative potency of clobetasol propionate ointment compared to other clobetasol propionate preparations in the treatment of psoriasis. Relevant literature was identified by PubMed and Google searches. We included studies of psoriasis that reported the percentage of subjects that achieved desired efficacy endpoints, as well as studies that reported the subjects' mean change in symptoms from baseline. We excluded studies conducted before 1980 and those that allowed concomitant treatments. OBSERVATIONS: Efficacy rates ranged from 17% to 80% for the different vehicles: ointment, solution, foam, cream, lotion, shampoo, and emollient. CONCLUSIONS: Clobetasol propionate is a very effective treatment for psoriasis. Ointment preparations have similar efficacy to other preparations in clinical trial situations. In clinical practice, a situation in which patient preferences are more likely to affect compliance, it may be best to choose whichever vehicle patients find preferable.

Administration, Topical↗

PubMed2006

Would elimination of copayments for phototherapy decrease the cost of treating psoriasis with systemic biologics? A cost analysis.

Phototherapy is a proven treatment method for the treatment of psoriasis, yet is typically underutilized because of the frequency of physician visits and copayments required for each session (typically 2-5 treatments/wk). Injectable biologic therapies are effective but costly. The objective of this study was to explore how changes in copayment strategies for phototherapy may affect biologic usage. Published estimates of the cost of phototherapy and biologic treatment were used to determine the costs of these treatments to patients and insurers. With an estimated patient copayment of $30 per office visit and a pharmacy copayment of $50 per month, the $1,800 annual patient expense for phototherapy far exceeds the estimated out-of-pocket expenses for etanercept, alefacept, and efalizumab ($840, $405, and $780, respectively). The estimated annual costs to MCOs ranged from $3,008 for phototherapy, to $20,300 for etanercept. Copayments for phototherapy may be shifting patients toward biologic treatment, which is more convenient but more costly to managed care plans.

Cost Sharing↗

PubMed2006

Race and medication adherence in Medicaid enrollees with type-2 diabetes.

OBJECTIVE: The association of medication adherence with race has been inadequately studied previously in type-2 diabetes patients. The study objective was to determine the association between race and medication adherence among type-2 diabetes patients. METHODS: This was a retrospective cohort study, which compared medication adherence among different races of Medicaid insured patients with type-2 diabetes newly starting oral antidiabetic medication. A total of 1,527 African-American patients newly starting antidiabetic medication between July 2001 and June 2002 were compared with 1,128 white patients and 514 patients of other race. Medication adherence was measured as medication possession ratio using prescription refill patterns. Multivariate regression analyses were used to determine the difference in adherence rates adjusting for other covariates. RESULTS: Medication adherence rate was significantly higher for whites [0.59 (0.31)] as compared to African Americans [0.54 (0.31), (p<0.05)]. In multivariate analyses, the adherence rate of African-American patients was found to be significantly lower by 12% as compared to whites after adjusting for other covariates. Metformin users were associated with a 62% decrease in adherence rate as compared with the sulfonylureas group (p<0.05). CONCLUSION: The antidiabetic medication adherence was associated with race. Future research should investigate patient-related factors affecting medication adherence in type-2 diabetes patients.

Adolescent↗

PubMed2005

Limited availability of psoriasis and phototherapy care: an analysis of advertisements.

Because the number of dermatologists remains stable, patients with medical dermatologic conditions such as psoriasis may find it increasingly difficult to access dermatological treatment. Measuring the competition in the marketing of dermatologic care may provide insight into the availability of dermatology services. The purpose of this study was to determine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. We performed a quantitative and qualitative assessment of dermatologists' Yellow Pages advertisements in small cities and the ten largest metropolitan regions in the country. Per capita, more advertisements were found in smaller markets than larger markets and a higher percentage was descriptive rather than just a name, address and phone number. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. Cosmetic ads were more prevalent in larger markets. In all regions, psoriasis and psoriasis treatment ads were least common. These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis. Efforts to promote psoriasis care should be encouraged.

Advertising↗