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BACKGROUND: Decisions regarding how to treat patients who have 1 to 3 brain metastases require important tradeoffs between controlling recurrences, side effects, and costs. In this analysis, the authors compared novel treatments versus usual care to determine the incremental cost-effectiveness ratio from a payer's (Medicare) perspective. METHODS: Cost-effectiveness was evaluated using a microsimulation of a Markov model for 60 one-month cycles. The model used 4 simulated cohorts of patients aged 65 years with 1 to 3 brain metastases. The 4 cohorts had a median survival of 3, 6, 12, and 24 months to test the sensitivity of the model to different prognoses. The treatment alternatives evaluated included stereotactic radiosurgery (SRS) with 3 variants of salvage after recurrence (whole-brain radiotherapy [WBRT], hippocampal avoidance WBRT [HA-WBRT], SRS plus WBRT, and SRS plus HA-WBRT). The findings were tested for robustness using probabilistic and deterministic sensitivity analyses. RESULTS: Traditional radiation therapies remained cost-effective for patients in the 3-month and 6-month cohorts. In the cohorts with longer median survival, HA-WBRT and SRS plus HA-WBRT became cost-effective relative to traditional treatments. When the treatments that involved HA-WBRT were excluded, either SRS alone or SRS plus WBRT was cost-effective relative to WBRT alone. The deterministic and probabilistic sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: HA-WBRT and SRS plus HA-WBRT were cost-effective for 2 of the 4 cohorts, demonstrating the value of controlling late brain toxicity with this novel therapy. Cost-effectiveness depended on patient life expectancy. SRS was cost-effective in the cohorts with short prognoses (3 and 6 months), whereas HA-WBRT and SRS plus HA-WBRT were cost-effective in the cohorts with longer prognoses (12 and 24 months). Cancer 2015;121:4231-9. V C 2015 American Cancer Society.KEYWORDS: cognition disorders, computer-assisted radiotherapy, cost-effectiveness analysis, image-guided radiotherapy, secondary brain neoplasm. INTRODUCTIONBrain metastases are the most common intracranial tumors in adults and are a morbid consequence of disseminated cancer. Uncontrolled brain metastases cause headaches, neurocognitive dysfunction, seizures, and eventually death. 1 With improvements in systemic treatment and the more routine use of magnetic resonance imaging (MRI) for surveillance, the incidence of brain metastases is likely to continue to increase. 1 Given the inadequate penetration of systemic therapies across the blood-brain barrier, cranial irradiation remains the standard treatment for brain metastases. Although radiation treatment can reduce or eliminate the morbidity caused by intracranial tumors, it can also cause neurocognitive toxicity, including cognitive deterioration and cerebellar dysfunction. 2 The recognition that traditional whole-brain radiotherapy (WBRT) is associated with a significant tradeoff in terms of benefit versus harm has led to recent developments of newe...

Introduction:Socio-economic status (SES) and low health literacy (LHL) are closely correlated. Both are directly associated with clinical and behavioral risk factors and healthcare outcomes. Learning healthcare systems are introducing small-area measures to address the challenges associated with maintaining patient-reported measures of SES and LHL. This study’s purpose was to measure the association between two available census block measures associated with SES and LHL. Understanding the relationship can guide the identification of a multi-purpose area based measure for delivery system use.Methods:A retrospective observational design was deployed using all US Census block groups in Utah. The principal dependent variable was a nationally-standardized health literacy score (HLS). The primary explanatory variable was a state-standardized area deprivation index (ADI). Statistical methods included linear regression and tests of association. Receiver operating characteristic (ROC) analysis was used to develop LHL criteria using ADI.Results:A significant negative association between the HLS and the ADI score remained after adjusting for area-level risk factors (β: –0.21 (95% CI: –0.22, –0.19) p < .001). Eighteen block groups (<1%) were identified as having LHL using HLS. A combination of three or more ADI components correlated with LHL predicted 78% of HLS LHL block groups and 35 additional block groups not identified using HLS (c-statistic: 0.64; 95% CI: 0.62, 0.66).Conclusions:HLS and ADI use differing measurement criteria but are closely correlated. A state-based ADI detected additional neighborhoods with risk of LHL compared to use of a national HLS. An ADI represents a multi-purpose area measure of social determinants useful for learning health systems tailoring care.

Objective Medicare Part D claims indicate medication purchased, but people who are not fully adherent may extend prescription use beyond the interval prescribed. This study assessed concordance between Part D claims and medication possession at a study visit in relation to self-reported medication adherence. Methods We matched Part D claims for six common medications to medications brought to a study visit in 2011–2013 for the Atherosclerosis Risk in Communities Study (ARIC). The combined data consisted of 3,027 medication events (claims, medications possessed or both) for 2,099 ARIC participants. Multinomial logistic regression estimated the association of concordance (Visit Only, Part D Only, or Both) with self-reported medication adherence while controlling for socio-demographic characteristics, veteran status, and availability under Generic Drug Discount Programs (GDDPs). Results Relative to participants with high adherence (p<0.05), medication events for participants with low adherence were approximately 25 percentage points less likely to match and more likely to be Visit Only. The results were similar but smaller in magnitude (approximately 2–3 percentage points) for participants with medium adherence. Compared to females, medication events for male veterans were approximately 11 percentage points less likely to match and more likely to be Visit Only. Events for medications available through GDDP were 3 percentage points more likely to be Visit Only. Conclusions Part D claims were substantially less likely to be concordant with medications possessed at study visit for participants with low self-reported adherence. This result supports the construction of adherence proxies such as proportion days covered using Part D claims.

Background Variation in outcomes by race/ethnicity in adults with heart failure (HF) has been previously observed. Identifying factors contributing to these variations could help target interventions. We evaluated the association of race/ethnicity with HF outcomes and potentially contributing factors within a contemporary HF cohort. Methods and Results We identified members of Kaiser Permanente Northern California, a large integrated healthcare delivery system, who were diagnosed with HF between 2012 and 2016 and had at least 1 year of prior continuous membership and left ventricular ejection fraction data. We used Cox regression with time‐dependent covariates to evaluate the association of self‐identified race/ethnicity with HF or all‐cause hospitalization and all‐cause death, with backward selection for potential explanatory variables. Among 34 621 patients with HF, compared with White patients, Black patients had a higher rate of HF hospitalization (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18–1.38) but a lower rate of death (adjusted HR, 0.78; 95% CI, 0.72–0.85). In contrast, Asian/Pacific Islander patients had similar rates of HF hospitalization, but lower rates of all‐cause hospitalization (adjusted HR, 0.89; 95% CI, 0.85–0.93) and death (adjusted HR, 0.75; 95% CI, 0.69–0.80). Hispanic patients also had a lower rate of death (adjusted HR, 0.85; 95% CI, 0.80–0.91). Sensitivity analyses showed that effect sizes for Black patients were larger among patients with reduced ejection fraction. Conclusions In a contemporary and diverse population with HF, Black patients experienced a higher rate of HF hospitalization and a lower rate of death compared with White patients. In contrast, selected outcomes for Asian/Pacific Islander and Hispanic patients were more favorable compared with White patients. The observed differences were not explained by measured potentially modifiable factors, including pharmacological treatment. Future research is needed to identify explanatory mechanisms underlying ongoing racial/ethnic variation to target potential interventions.

Background: Health systems are increasingly recognizing the importance of collecting social determinants of health (SDoH) data. However, gaps remain in our understanding of facilitators or barriers to collection. To address these gaps, we evaluated a real-world implementation of a SDoH screening tool. Methods: We conducted a retrospective analysis of the implementation of the SDoH screening tool at Mayo Clinic in 2019. The outcomes are: (1) completion of screening and (2) the modality used (MyChart: filled out on patient portal; WelcomeTablet: filled out by patient on a PC-tablet; EpicCare: data obtained directly by provider and entered in chart). We conducted logistic regression for completion and multinomial logistic regression for modality. The factors of interest included race and ethnicity, use of an interpreter, and whether the visit was for primary care. Results: Overall, 58.7% (293,668/499,931) of screenings were completed. Patients using interpreters and racial/ethnic minorities were less likely to complete the screening. Primary care visits were associated with an increase in completion compared with specialty care visits. Patients who used an interpreter, racial and ethnic minorities, and primary care visits were all associated with greater WelcomeTablet and lower MyChart use. Conclusion: Patient and system-level factors were associated with completion and modality. The lower completion and greater WelcomeTablet use among patients who use interpreters and racial and ethnic minorities points to the need to improve screening in these groups and that the availability of the WelcomeTablet may have prevented greater differences. The higher completion in primary care visits may mean more outreach is needed for specialists.

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Rationale, aims and objectives Prolongation of the corrected QT (QTc) interval is associated with increased morbidity and mortality. The association between QTc interval-prolonging medications (QTPMs) and risk factors with magnitude of QTc interval lengthening is unknown. We examined the contribution of risk factors alone and in combination with QTPMs to QTc interval lengthening. Method The ARIC Study assessed 15,792 participants with a resting, standard 12-lead electrocardiogram and ≥ 1 measure of QTc interval over four examinations at three-year intervals (1987–1998). From 54,638 person-visits, we excluded participants with QRS ≥ 120 ms (n=2,333 person-visits). We corrected the QT interval using the Bazett and Framingham formulas. We examined QTc lengthening using linear regression for 36,602 person-visit observations for 14,160 controlling for age ≥ 65 years, female sex, left ventricular hypertrophy, QTc > 500 ms at the prior visit and CredibleMeds® categorized QTPMs (Known, Possible, or Conditional risk). We corrected standard errors for repeat observations per person. Results Eighty percent of person-visits had at least one risk factor for QTc lengthening. Use of QTPMs increased over the four visits from 8% to 17%. Among persons not using QTPMs, history of prolonged QTc interval and female sex were associated with the greatest QTc lengthening, 39 ms and 12 ms, respectively. In the absence of risk factors, Known QTPMs and ≥ 2 QTPMs were associated with modest but greater QTc lengthening than Possible or Conditional QTPMs. In the presence of risk factors, ≥ 2 QTPM further increases QTc lengthening. In combination with risk factors, the association of all QTPM categories with QTc lengthening was greater than QTPMs alone. Conclusion Risk factors, particularly female sex and history of prolonged QTc interval, have stronger associations with QTc interval lengthening than any QTPM category alone. All QTPM categories augmented QTc interval lengthening associated with risk factors.