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The effectiveness of a pharmacist-led telephone intervention directed at providers or members was examined in this randomized study. Pharmacist calls to members did not improve osteoporosis management over member and provider mail and fax notifications. Greater impact was demonstrated by performing a pharmacist call intervention with providers rather than with members.
Background Examining drug exposure is essential to pharmacovigilance, especially for bisphosphonate (BP) therapy. Objective This study examines differences in four measures of oral BP exposure: treatment discontinuation, adherence, persistence, and non-persistence. Methods Among women aged ≥50 years who initiated oral BP therapy during 2002–2007 with at least three years of health plan membership follow-up, discontinuation was defined by evidence of no further treatment during the study observation period. Among those with at least two filled BP prescriptions during the study period, adherence was calculated for each year of follow-up using the proportion of days covered, modified to allow for stockpiling of prescription/refills overlap ≤30 days supply (mPDC). Persistence was quantified by treatment duration, allowing a gap of up to 60 days between prescription/refill days covered. Non-persistence was quantified by the periods without drug outside this allowable gap. Multivariable logistic regression was used to compare age and race groups and the relationships of early adherence (adherence during the first year) with subsequent adherence. Results Among 48,390 women initiating oral BP therapy and followed for three years, 26.7% discontinued in Year 1 and 14.7% of the remaining 35,456 women discontinued in Year 2. Discontinuation rates were slightly higher (29.4%, p<0.001) for women age ≥75 years and somewhat lower (21.1%, p<0.001) for Asian women. During the first year, 60.4% achieved a mPDC of ≥75%, with demographic differences in adherence similar to that seen for treatment discontinuation. Over the three years, the median mPDC levels for BP therapy were 86%, 84% and 85% in Years 1, 2 and 3, respectively for those receiving treatment. Cumulative persistence was 2.3 years (median, IQR 1.0–3.0) overall and slightly greater for Asian versus white women and lower for older women. There were 18,174 (42.9%) women with at least one period of non-persistence during three years follow-up in excess of the 60 day allowable gap between prescription/refills (median cumulative non-persistence 0.65, IQR 0.30–1.25 years). Women with mPDC ≥75% during the first year had a 12-fold and 6-fold increased odds of mPDC ≥75% during Year 2 and Year 3, respectively. Conclusions Bisphosphonate discontinuation rates are highest for women during the first year. Among those continuing treatment in subsequent years, adherence rates were relatively stable. Persistence and adherence varied slightly by age and was somewhat higher in Asians, contributing to differences in cumulative bisphosphonate exposure. We also found evidence that optimal adherence in the first year was highly predictive of optimal adherence in the subsequent one to two years. Hence, subgroups of patients receiving oral bisphosphonate drugs may require different levels of support and monitoring to maximize treatment benefit, especially based on early patterns of use.
Surgeon case volume had positive impacts on procedural, financial, and clinical outcomes and this finding may be used to improve hospital's quality of care.
Introduction: Cancer care costs escalated with the introduction of novel therapies. Therefore, cancer-related Cost Utility Analyses (CUAs) are used to guide policy makers. Since numerous methods (criteria) exist to evaluate CUAs, we compared these criteria between CUAs of solid tumors and those of hematological malignancies. Methods:A systemic MEDLINE search of English-language publications between 2001 and 2012 was performed. Strict inclusion criteria were limited to CUAs examining one single intervention and one single study comparator. Standard data of 66 variables, based on the Drummond criteria, were collected to review each CUA for clarity, completeness, and health economic methodological quality.Results: Among 8,515 screened papers on Pubmed, 177 cancer-related CUAs (2%) were eligible. Solid tumors and hematological malignancies CUAs constituted 161(91%) and 16(9%). Among the standardized methods for evaluating CUAs, those of solid tumors reported more frequently the presentation of cost-effectiveness acceptability curve (p=0.02) and the use of threshold value to interpret study results (p=0.024) than those of hematological malignancies. Further, CUAs of solid tumors were more frequently multicenter-based (p=0.014); however, CUAs of hematological malignancies listed differential quality adjusted life year separately more frequently (p=0.02). Outcomes of CUAs of solid tumors were more frequently reported as significant (p=0.014). Conclusions:CUAs of solid tumors abided more frequently with the standardized methods (criteria) than those of hematological malignancies, which may be due in part to their multiple study sites. CUAs of hematological malignancies may warrant more methodological standardization and incorporate more study sites. MethodsA systemic MEDLINE search by the keywords: CUAs and cancer of English-language manuscripts published between 2001 and 2012 was performed. Eligibility criteria consisted of including only CUAs that examined one single intervention and one single study comparator. For example, adding rituximab to fludarabine and cyclophosphamide for the treatment of previously untreated chronic lymphocytic leukemia [15]. Exclusion criteria included CUAs that examined more than one intervention, more than one comparator or more than one study population or type of malignancy. The study population was not limited by age; therefore, CUAs examining children, adult or geriatric populations were included.
Introduction Decitabine (Dec) is not approved in the United States (US) for acute myeloid leukemia (AML) because it did not improve overall survival compared with standard conventional induction treatment. We asked what would be the cost effectiveness of Dec versus conventional induction therapy in AML patients (pts) older than 60 years of age. Methods The standard conventional induction including cytarabine, and daunorubicin, (AD) (N Engl J Med. 2009 361:1235-48) was compared with Dec (Haematologica. 2012 97:393-401) using a semi-Markov model compiling survival and cost data. Survival probabilities were retrieved from the literature. Data accounted for re-induction therapy with IDA-FLAG (idarubicin, fludarabine, cytarabine and granulocyte colony-stimulating factor) and consolidation therapy with high-dose cytarabine (HiDAC) but not for stem cell transplantation. The assumption-based model considered a maximum of 4 cycles of HiDAC and continuing Dec until loss of benefit. Drug costs were derived from the 2012 US market. Hospital costs accrued were evaluated in a diagnosis-related group (DRG) system. Drug dosage was estimated based on a body surface area of 1.85 m2. The quality of life (QoL) was assumed as 1 for healthy individuals; 0 for death; 0.524 for active disease; 0.91 for AML in remission on AD; 0.71 and 0.524 for AML being actively treated with Dec or AD, and 0.81 for AML in remission treated with Dec or HIDAC. QoL data were based on the literature except for pts on consolidation therapy. The latter was the mean of QoL of AML in remission and AML actively being treated. Results Assuming 1,000 pts for each treatment arm in a semi-Markov model over 1 year time horizon, the quality-adjusted life year (QALY) for AD vs. Dec was 0.1754 and 0.5982. The percentage survival for AD and Dec was 45.2% and 50.5%. Their costs were $127,867 and $55,777. The incremental cost-effectiveness ratio (ICER) was -$72,090/0.4228 = -$170,506/year. By sensitivity analysis, Dec was superior to AD to all parameters (Table 1). Conclusion Dec is a more cost-effective therapy for pts older than 60 years of age than conventional induction therapy. Given the economic pressures in the US Health System, one should consider approving Dec for newly diagnosed AML pts older than 60 years of age. Disclosures: No relevant conflicts of interest to declare.
Objectives: To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk non-muscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options.Methods: Bladder cancer patients age ≥21 years with cystectomy/UD performed from 1/2010 to 6/2015 in three Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect.Results: Of 991 eligible patients, 794 (80%) received IC. 169 surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (ICC=.26). The multilevel model with only patient factors showed good fit (AUC=.93, Hosmer-Lemeshow test p=. 44), and older age, female sex, eGFR<45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs. NB/CP. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (p=.29). Conclusions:In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.
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