Hospitalizations and healthcare costs associated with rifaximin versus lactulose treatment among commercially insured patients with hepatic encephalopathy in the United States

AIMS

To assess healthcare costs and hospitalization rates associated with rifaximin therapy versus lactulose alone among patients at risk for hepatic encephalopathy (HE).

METHODS AND MATERIALS

IBM Marketscan Commercial and Optum's de-identified Clinformatics Data Mart databases were used separately to identify commercially insured HE patients treated with rifaximin or lactulose alone, using an algorithm developed with clinical experts. HE-related hospitalizations were defined based on an algorithm using diagnosis codes and diagnosis-related group codes. HE-related/all-cause hospital admissions/days and healthcare costs were compared between rifaximin and lactulose episodes using incidence rate ratios and adjusted cost differences.

RESULTS

In Marketscan, there were 13,515 [Optum: 5,217] rifaximin episodes and 9,946 [4,897] lactulose alone episodes included. Yearly rates of HE-related hospital admissions decreased by 33% [34%] when treated with rifaximin versus lactulose alone, and rates of HE-related hospital days similarly decreased by 43% [57%]. Yearly rates of all-cause hospital admissions decreased by 27% [27%]; rates of all-cause hospital days decreased by 33% [37%] during rifaximin episodes versus lactulose alone. This translated to $2,417 [$2,301] and $173 [$397] lower total mean medical costs and HE-related hospital costs per-patient-per-month, respectively (p < .05). Despite increased pharmacy costs associated with rifaximin, there was no change in total healthcare costs. Patients adherent to rifaximin incurred $2,891 [$2,340] lower total healthcare costs than non-adherent patients. In a simulated plan of 1 million lives, if 50% of HE patients treated with lactulose alone had rifaximin added on and were adherent to rifaximin therapy, the total cost savings would be $7.5 [$6.1] million per year ($0.62 [$0.50] per-member-per-month).

CONCLUSIONS

Patients incurred significantly lower rates of HE-related and all-cause hospitalizations during rifaximin versus lactulose episodes, resulting in lower facility and professional costs. Cost savings may be possible if rifaximin adherence is improved in HE patients.

LIMITATIONS

The study is subject to limitations common to claims-based analyses.

Burden of Infections Among Chronic Myeloid Leukemia Patients Receiving Dasatinib or Nilotinib: A Real-World Retrospective Healthcare Claims Study in the United States

INTRODUCTION

Tyrosine kinase inhibitors (TKI) have been demonstrated to prolong survival in patients with chronic myeloid leukemia (CML). However, TKIs may be associated with an increased risk of infections. This study compared healthcare resource utilization (HRU) and costs among patients with CML receiving dasatinib or nilotinib, with a focus on infection-related economic outcomes.

METHODS

Two large administrative databases were used to identify adult patients newly diagnosed with CML who initiated dasatinib or nilotinib as first- (1L) or second-line (2L) therapy and were classified into the following 1L (dasatinib 1L/nilotinib 1L cohorts) or 2L (dasatinib 2L/nilotinib 2L) cohorts based on the initiated 1L/2L TKI therapy. Infection-related HRU and healthcare costs were compared between cohorts, separately for 1L and 2L.

RESULTS

Cohorts included 1156 patients in the dasatinib 1L and 677 patients in the nilotinib 1L cohorts, 322 patients in the dasatinib 2L, and 207 in the nilotinib 2L cohorts. In 1L and 2L, infection-related HRU was higher for dasatinib than nilotinib cohorts. Infection-related inpatient (IP) days constituted a larger proportion of all-cause IP days in the 1L/2L dasatinib than 1L/2L nilotinib cohorts (dasatinib 1L/2L: 53%/58%; nilotinib 1L/2L: 50%/46%). Compared to the nilotinib cohort, the dasatinib cohort had higher all-cause total costs per patient per year by US$17,901 in 1L and $28,625 in 2L. Of the total cost difference, infection-related were $6048 (34%) in 1L and $28,192 (99%) in 2L, largely driven by IP cost differences (1L/2L: 96%/98%).

CONCLUSIONS

Dasatinib was associated with higher HRU and healthcare costs compared to nilotinib, particularly related to infections.

FUNDING

Novartis Pharmaceutical Corporation.

Assessing utility values for treatment-related health states of acute myeloid leukemia in the United States

Background

Preference valuations of health status are essential in health technology and economic appraisal. This study estimated utilities for treatment-related health states of acute myeloid leukemia (AML) and disutilities of severe adverse events (SAEs) using a representative sample of adults from the general population in the United States (US).

Methods

Treatment-related AML health states, defined based on literature and interviews with clinicians, included complete remission (CR), no CR, relapse, stem cell transplant (SCT), and post SCT short-term recovery. Six attributes with varying levels, including fever, lack of energy, problems with daily function, anxiety/depression, blood transfusions, and hospitalization, were used to define health states. An online survey using discrete choice experiment methodology was designed to capture preferences for health status scenarios including the identified attributes and key grade 3/4 chemotherapy-related SAEs. Health state utilities and SAE disutilities were generated from a conditional logistic regression with generalized estimating equations.

Results

Of the 300 survey participants, the demographic distributions were within a 3% margin of those in the 2010 US Census. CR had the highest utility value (0.875), followed by post-SCT short-term recovery (0.398), relapse (0.355), no CR (0.262), and SCT (0.158). Of the SAEs, serious infection had the highest decline in utility (0.218), followed by severe diarrhea (0.176), abnormally low blood cell counts (0.100), and severe redness/skin peeling (0.060).

Conclusions

AML and treatments can result in reduced quality of life and impaired ability to perform daily activities. Findings of this study underline the value that society places on treatment-related AML health states and SAEs.

Treatment patterns, healthcare resource utilization, and costs in patients with acute myeloid leukemia in commercially insured and Medicare populations

OBJECTIVE

To describe the setting, duration, and costs of induction and consolidation chemotherapy for adults with newly-diagnosed acute myeloid leukemia (AML), who are candidates for standard induction chemotherapy, in the US.

METHODS

Adults newly-diagnosed with AML who received standard induction chemotherapy in an inpatient setting were identified from the Truven Health Analytics MarketScan (2006-2015) and SEER-Medicare (2007-2011) databases. Patients were observed from induction therapy start to the first of hematopoietic stem cell transplant, 180 days after induction discharge, health plan enrollment/data availability end, or death. Induction and consolidation chemotherapy were identified using Diagnosis-Related Group codes (chemotherapy with acute leukemia) or procedure codes for AML chemotherapy administration. AML treatment episode setting (inpatient or outpatient), duration, and costs (2015 USD, payers' perspective) were described for commercially insured patients and Medicare beneficiaries.

RESULTS

In total, 459 commercially insured patients and 563 Medicare beneficiaries (mean age = 54 and 66 years; 53% and 54% male; respectively) were identified. For induction therapy, mean costs were $145,189 for commercially insured patients and $85,734 for Medicare beneficiaries, and median inpatient duration was 31 days (both). Following induction, 64% of commercially insured patients and 53% of Medicare beneficiaries had ≥1 consolidation cycle; 75% and 65% of consolidation cycles were in an inpatient setting, respectively. For consolidation cycles, in the inpatient setting, mean costs were $28,137 for commercially insured patients and $28,843 for Medicare beneficiaries, median cycle duration was 6 days (both); in the outpatient setting, mean costs were $11,271 for commercially insured patients and $5,803 Medicare beneficiaries, median duration was 5 days (both).

LIMITATIONS

Granular information on chemotherapy type administered was unavailable.

CONCLUSIONS

This is the first exploratory study providing a complete picture of recent AML treatment patterns and management costs among commercially insured patients and Medicare beneficiaries. There is substantial heterogeneity in the management and costs of AML.

Health Care Resource Utilization and Costs in Patients with Chronic Myeloid Leukemia with Better Adherence to Tyrosine Kinase Inhibitors and Increased Molecular Monitoring Frequency

BACKGROUND

Frequent molecular monitoring (qPCR tests), as recommended by evidence-based monitoring guidelines, is associated with higher adherence to tyrosine kinase inhibitors (TKIs) in the management of chronic myeloid leukemia (CML); both factors have been associated with better clinical and economic outcomes.

OBJECTIVES

To (a) estimate the effect of more frequent qPCR tests on health care resource utilization (HRU) and associated costs, including direct (effect of qPCR test frequency on HRU) and indirect (through TKI adherence) effects, and (b) develop an economic model applicable to multiple clinical practice scenarios.

METHODS

Adult patients newly diagnosed with CML who started TKI firstline therapy were identified from U.S. administrative claims data (2010-2015). TKI adherence (medication possession ratio [MPR]), number of inpatient days, emergency room (ER) visits, outpatient service days, and mean costs per HRU event were measured during the first year of CML treatment. Direct and indirect effects of qPCR test frequency were estimated using multivariate regression models. Subsequently, an economic model was developed to assess the overall effect of varying qPCR test frequency on HRU and associated costs during the first year of CML treatment under different clinical practice scenarios; the scenario reported is the increase from 1 to 2 qPCR tests.

RESULTS

Of the 1,431 patients included, 36% had no qPCR tests, the average qPCR test frequency was 1.6, and the average MPR was 0.86 during the first year of CML treatment. The direct effect of increasing qPCR test frequency by 1 was associated with 13.0% fewer inpatient days (adjusted incidence rate ratio [adjusted IRR] = 0.87; P = 0.010); 8.3% fewer ER visits (adjusted IRR = 0.92; P = 0.043); and 3.0% more outpatient service days (adjusted IRR = 1.03; P = 0.002). Each increase of 1 test was associated with an increase in TKI adherence by 2.2 percentage points (adjusted MPR difference = 0.022; P < 0.001). When considering the indirect effect of qPCR test frequency through TKI adherence, an increase of 1 qPCR test combined with an increase in TKI adherence by 2.2 percentage points was associated with a greater reduction of inpatient days from 13.0% to 15.2%, ER visits from 8.3% to 8.6%, and a smaller increase of outpatient service days from 3.0% to 2.6%. Based on the economic model, an increase from 1 to 2 qPCR tests, considering the increase in TKI adherence, was associated with a reduction of 0.87 (95% CI = -1.49, -0.18) inpatient days and 0.06 (95% CI = -0.12, 0.05) ER visits, an increase of 0.98 (95% CI = 0.25, 1.60) outpatient service days and a cost savings of $2,918 (95% CI = -5,213, -349) per patient per year.

CONCLUSIONS

Closer alignment with the monitoring guidelines' recommended qPCR test frequency and better adherence to TKIs were associated with lower HRU and medical service costs. Managed care initiatives to increase qPCR test frequency and TKI adherence might benefit from an enhanced reduction because of the interaction between both factors.

DISCLOSURES

This study was funded by Novartis Pharmaceuticals, which was involved in all stages of the study and in the decision to submit the report for publication. Latremouille-Viau, Guerin, Gagnon-Sanschagrin, and Dea are employees of Analysis Group, which received consulting fees from Novartis Pharmaceuticals for work on this study. Joseph is an employee of Novartis Pharmaceuticals and owns stock in Amgen and Pfizer. Cohen was an employee of Novartis Pharmaceuticals at the time of this study. Portions of this study were presented online (beginning May 20, 2016) as part of the American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago, Illinois, on June 3-7, 2016, and as a poster at the American Society of Hematology (ASH) Annual Meeting in San Diego, California, on December 3-6, 2016. Study concept and design were contributed by Latremouille-Viau and Guerin, along with the other authors. Gagnon-Sanschagrin and Dea took the lead in data collection, assisted by the other authors, and data interpretation was performed by Cohen and Joseph, along with the other authors. The manuscript was written by Latremouille-Viau, along with the other authors, and revised by Joseph, along with the other authors.

Tyrosine kinase inhibitor (TKI) therapy discontinuation in patients with CML in chronic phase: A US clinical practice perspective

7052

Background: This study assessed TKI discontinuation practice in the US before the publication of new practice guidelines in November 2016 including recommendations on TKI discontinuation for patients (pts) with CML in chronic phase (CML-CP). Methods: From 10/12/2016 to 11/9/2016, 300 US oncologists/hematologists completed a survey on the reasons for TKI discontinuation in pts with CML-CP, their perspective on adequate response pts should achieve before considering TKI discontinuation (minimum response to TKI, response duration, and TKI therapy duration), and post-discontinuation CML monitoring. Results: One third of participating physicians reported having attempted TKI discontinuation (102 of 300); 66 did so outside of a clinical trial. Physicians who reported TKI discontinuation were more likely to practice in academic centers; were more experienced clinicians ( > 10 years in practice); and followed a larger number of CML pts vs those who did not. Among the 66 physicians, the majority would consider TKI discontinuation for medical reasons (76% adverse events, 47% pregnancy planning), with fewer for economic reasons (35%); 12% reported they would consider it for all of their pts who achieve an adequate response. There was no consensus on the minimum response achieved (56% consider a decrease in BCR-ABL of ≥4.5 log, 21% 3 log, and 11% 1 log), the minimum response duration (29% 3 yrs, 24% 2 yrs, and 20% 1 yr), and the minimum TKI therapy duration (44% 3yrs, 20% 2 yrs, 19% 1 yr) before TKI discontinuation. There was no consensus on the frequency of CML monitoring post-discontinuation with < 10% of physicians considering monthly molecular monitoring in the first year. Conclusions: TKI discontinuation in pts with CML-CP responding to TKI was attempted outside of clinical trials without clear guidelines. Conditions under which TKI therapy was discontinued differed from new recommended practice guidelines, which may have resulted in discontinuation where deep response may not be achieved and disease not adequately monitored. The recommended practice guidelines need to be communicated to physicians as TKI discontinuation is likely to be conducted in a broader population.

Treatment patterns and healthcare costs among newly-diagnosed patients with chronic myeloid leukemia receiving dasatinib or nilotinib as first-line therapy in the United States

OBJECTIVE

To compare treatment patterns and economic outcomes of dasatinib and nilotinib as 1st-line therapies for chronic myeloid leukemia (CML).

METHODS

Adult CML patients initiated on first-line dasatinib or nilotinib in 2010-2014 were identified from two large US administrative claims databases. Treatment patterns, tyrosine kinase inhibitor (TKI) adherence and healthcare resource utilization (HRU) and costs were measured from the 1st-line TKI initiation (index date) to the end of follow-up.

RESULTS

A total of 604 and 418 patients were included in the dasatinib and nilotinib cohorts (mean ages = 50.9 and 52.5 years, 46.4% and 45.7% female), respectively. Among the dasatinib patients, 91% started with 100 mg/day, 3% with <100 mg/day, and 6% with >100 mg/day. Among the nilotinib patients, 76% started with 600 mg/day, 16% with >600 mg/day, and 8% <600 mg/day. The dasatinib cohort had a higher hazard of dose decrease (hazard ratio [HR] = 1.66; p = .002) and of switching to another TKI (HR =1.62; p = .019) compared to the nilotinib cohort. The hazard of dose increase (HR =0.76; p = .423) and treatment discontinuation (HR =1.10; p = .372) were not significantly different between cohorts. There was also no significant difference in TKI adherence levels (mean proportion of days covered [PDC] difference over first 6 months = -0.0003, p = .981; mean PDC difference over first 12 months = -0.0022, p = .880) and HRU (inpatient day incidence rate ratio [IRR] = 1.03, p = .930; emergency room IRR =1.26, p = .197; and days with outpatient services IRR = 1.01, p = .842). The dasatinib cohort incurred higher healthcare costs by $749 per patient per month (p = .044) compared to the nilotinib cohort.

LIMITATION

Information on CML phase and Sokal score was not available.

CONCLUSIONS

Dasatinib was associated with an increased hazard of dose decrease and switching to another TKI and higher healthcare costs, vs nilotinib.

Clinical Outcomes and Biologic Costs of Switching Between Tumor Necrosis Factor Inhibitors in US Veterans with Rheumatoid Arthritis

Introduction

The purpose of this study was to evaluate clinical outcomes and drug/administration costs of treatment with tumor necrosis factor inhibitor (TNFi) agents in US veterans with rheumatoid arthritis (RA) initiating TNFi therapy. The analysis compared patients initiating and continuing a single TNFi with patients who subsequently switched to a different TNFi.

Methods

Data from patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry who initiated treatment with adalimumab, etanercept, or infliximab from 2003 to 2010 were analyzed. Outcomes included duration of therapy, Disease Activity Score based on 28 joints (DAS28), and direct drug and drug administration costs.

Results

Of 563 eligible patients, 262 initiated a single TNFi therapy, 142 restarted their initial TNFi after a ≥90-day gap in treatment (interrupted therapy), and 159 switched to a different TNFi. Patients who switched had higher mean DAS28 before starting TNFi therapy than patients with single or interrupted therapy: 5.3 vs 4.5 or 4.6, respectively. Mean duration of the first course was 34.3 months for single therapy, 18.3 months for interrupted therapy, and 17.7 months for switched therapy. Mean post-treatment DAS28 was highest for patients who switched TNFi. Mean annualized costs for first course were $13,800 for single therapy, $13,200 for interrupted therapy, and $14,200 for switched therapy; mean annualized costs for second course were $12,800 for interrupted therapy and $15,100 for switched therapy.

Conclusion

Patients who switched TNFi had higher pre-treatment DAS28 and higher overall costs than patients who received the same TNFi as either single or interrupted therapy.

Funding

This research was funded by Immunex Corp., a fully owned subsidiary of Amgen Inc., and by VA HSR&D Grant SHP 08-172.

Discontinuation of disease-modifying anti-rheumatic drugs and clinical outcomes in the Rheumatoid Arthritis DMARD Intervention and Utilisation Study 2 (RADIUS 2)

OBJECTIVES

The purpose of this analysis was to examine discontinuation and reasons for discontinuation from disease-modifying anti-rheumatic (DMARD) therapies in the RADIUS 2 registry, a long-term, open-label, observational study of patients with moderate to severe rheumatoid arthritis (RA).

METHODS

Patients who participated in RADIUS 2 initiated etanercept (ETN) therapy at study entry and were followed for 5 years. In this post hoc analysis, patients who had received ETN continuously from entry to month 4 were categorised by treatment at month 4: ETN monotherapy, ETN+methotrexate (MTX), ETN+MTX+other DMARDs (OTH), or ETN+OTH. Outcomes were assessed at month 4 and at the time of any subsequent treatment change, and included Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire Disability Index (HAQ-DI).

RESULTS

Of 3,484 patients analysed (982 ETN; 1,356 ETN+MTX; 537 ETN+MTX+OTH; 609 ETN+OTH), baseline demographic and clinical characteristics were similar across treatments. No treatment change occurred in 62.3%, 49.9%, 33.3%, and 37.1% of ETN, ETN+MTX, ETN+MTX+OTH, and ETN+OTH patients, respectively. The mean time on therapy from month 4 was longer for patients receiving ETN (23.3 months) or ETN+MTX (23.7 months) than those receiving ETN+MTX+OTH (18.0 months) or ETN+OTH (18.3 months). The greatest improvements in CDAI and HAQ-DI were seen in patients who continued on ETN. The most common reasons for discontinuing DMARD therapy were cost and ineffective treatment.

CONCLUSIONS

Most patients who had received ≥4 months of ETN continued on ETN throughout the 5-year observation period. Patients with greatest clinical and disability improvements tended to continue on ETN.

Cost and effectiveness of biologics for rheumatoid arthritis in a commercially insured population

BACKGROUND

Administrative claims contain detailed medication, diagnosis, and procedure data, but the lack of clinical outcomes for rheumatoid arthritis (RA) historically has limited their use in comparative effectiveness research. A claims-based algorithm was developed and validated to estimate effectiveness for RA from data for adherence, dosing, and treatment modifications.

OBJECTIVE

To implement the claims-based algorithm in a U.S. managed care database to estimate biologic cost per effectively treated patient.

METHODS

The cohort included patients with RA aged 18-63 years in the Optum Research Database who initiated biologic treatment between January 2007 and December 2010 and were continuously enrolled 6 months before through 12 months after the first claim for the biologic (the index date). Patients were categorized as effectively treated by the claims-based algorithm if they met all of the following 6 criteria in the 12-month post-index period: (1) a medication possession ratio ≥ 80% for subcutaneous biologics, or at least as many infusions as specified in U.S. labeling for intravenous biologics; (2) no increase in biologic dose; (3) no switch in biologics; (4) no new nonbiologic disease-modifying antirheumatic drug; (5) no new or increased oral glucocorticoid treatment; and (6) no more than 1 glucocorticoid injection. Drug costs (all biologics) and administration costs (intravenous biologics) were obtained from allowed amounts on claims. Biologic cost per effectively treated patient was defined as total 1-year biologic cost divided by the number of patients categorized by the algorithm as effectively treated with that index biologic. Sensitivity analysis was conducted to examine the total health care costs per effectively treated patient during the first year of biologic therapy.

RESULTS

A total of 5,474 individuals were included in the analysis. The index biologic was categorized as effective by the algorithm for 28.9% of patients overall, including 30.6% for subcutaneous biologics and 22.1% for intravenous biologics. The index biologic was categorized as effective in the first year for 32.7% of etanercept (794/2,425), 32.3% of golimumab (40/124), 30.2% of abatacept (89/295), 27.7% of adalimumab (514/1,857), and 19.0% of infliximab (147/773) patients. Mean 1-year biologic cost per effectively treated patient, as defined in the algorithm, was lowest for etanercept ($43,935), followed by golimumab ($49,589), adalimumab ($52,752), abatacept ($62,300), and infliximab ($101,402). The rank order in the sensitivity analysis was the same, except for golimumab and etanercept. 

CONCLUSIONS

Using a claims-based algorithm in a large commercial claims database, etanercept was the most effective and had the lowest biologic cost per effectively treated patient with RA.

Cost of tumor necrosis factor blockers per patient with rheumatoid arthritis in a multistate Medicaid population

Background

The purpose of this study was to estimate the annual cost per treated patient for the tumor necrosis factor (TNF) blockers, etanercept, adalimumab, and infliximab in rheumatoid arthritis (RA) patients covered by Medicaid.

Methods

The MarketScan Medicaid Multistate Database was used to identify adult RA patients who used etanercept, adalimumab, or infliximab (index agents) from 2007 to 2011. The index date was the first claim preceded by 180 days and followed by 360 days of continuous enrollment. Patients with other conditions for which these agents are approved by the US Food and Drug Administration were excluded. “Continuing” patients had one or more pre-index claim for their index biologic, and “new” patients did not. Cost per treated patient was calculated in the 360 day post-index period for each index agent as the total index drug and administration cost to the payer and the costs of switched-to agents divided by the number of patients who received the index agent.

Results

A total of 1,085 patients met the study criteria. Forty-eight percent received etanercept (n=521); 37% received adalimumab (n=405); and 15% received infliximab (n=159). Patient characteristics were similar across groups (mean age 47.4 years, 83% female). The annual cost per treated patient was lowest for etanercept ($18,466), followed by adalimumab ($20,983) and infliximab ($26,516). For all agents, annual costs were lower for new patients ($17,996 for etanercept, $18,992 for adalimumab, and $24,756 for infliximab) than for continuing patients ($19,004 for etanercept, $24,438 for adalimumab, and $28,127 for infliximab).

Conclusion

Etanercept had lower costs per treated patient than adalimumab or infliximab in both new and continuing Medicaid enrollees with RA.

Persistence and dose escalation of tumor necrosis factor inhibitors in US veterans with rheumatoid arthritis

OBJECTIVE

Limited evidence exists comparing the persistence, effectiveness, and costs of biologic therapies for rheumatoid arthritis in clinical practice. Comparative effectiveness studies are needed to understand real-world experience with these agents. We evaluated treatment patterns, costs, and effectiveness of tumor necrosis factor inhibitor (TNFi) agents in patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry.

METHODS

Observational data from the VARA registry and linked administrative databases were analyzed. Longitudinal data from VARA patients initiating adalimumab (ADA), etanercept (ETN), or infliximab (IFX) from 2003 (the date all agents were available within the Veteran Affairs) to 2010 were analyzed. Outcomes included Disease Activity Score using 28 joints (DAS28), treatment persistence, dose escalation, and direct costs of drugs and drug administration.

RESULTS

For 563 eligible patients, baseline DAS28, DAS28 improvements, and persistence on initial treatment were similar across agents. Fewer patients receiving ETN (n = 5/290; 2%) underwent dose escalation than did patients taking ADA (n = 32/204; 16%) or IFX (n = 44/69; 64%). Annual costs for first course of TNFi therapy were lower for injectable ADA ($13,100 US) and ETN ($13,500 US) than for intravenously administered IFX ($16,900 US).

CONCLUSION

Despite similar persistence and clinical disease activity for these TNFi agents, rates of dose escalation were highest with ADA and IFX. Higher overall costs were noted for IFX without increases in effectiveness.

Use of a validated algorithm to estimate the annual cost of effective biologic treatment for rheumatoid arthritis

OBJECTIVES

To estimate biologic cost per effectively treated patient with rheumatoid arthritis (RA) using a claims-based algorithm for effectiveness.

METHODS

Patients with RA aged 18-63 years in the IMS PharMetrics Plus database were categorized as effectively treated if they met all six criteria: (1) a medication possession ratio ≥80% (subcutaneous) or at least as many infusions as specified in US labeling (intravenous); (2) no biologic dose increase; (3) no biologic switch; (4) no new non-biologic disease-modifying anti-rheumatic drug; (5) no new or increased oral glucocorticoid; and (6) ≤1 glucocorticoid injection. Biologic cost per effectively treated patient was defined as total cost of the index biologic (drug plus intravenous administration) divided by the number of patients categorized by the algorithm as effectively treated. Similar methods were used for the index biologic in the second year and for a second biologic after a switch.

RESULTS

Rates that the index biologic was categorized as effective in the first year were 31.0% etanercept (2243/7247), 28.6% adalimumab (1426/4991), 28.6% abatacept (332/1160), 27.2% golimumab (71/261), and 20.2% infliximab (474/2352). Mean biologic cost per effectively treated patient, per the algorithm, was $50,141 etanercept, $53,386 golimumab, $56,942 adalimumab, $73,516 abatacept, and $114,089 infliximab. Biologic cost per effectively treated patient, using this algorithm, was lower for patients who continued the index biologic in the second year and higher after switching.

CONCLUSIONS

When a claims-based algorithm was applied to a large commercial claims database, etanercept was categorized as the most effective and had the lowest estimated 1-year biologic cost per effectively treated patient. This proxy for effectiveness from claims databases was validated against a clinical effectiveness scale, but analyses of the second year or the year after a biologic switch were not included in the validation. Costs of other medications were not included in cost calculations.

Estimating effectiveness and cost of biologics for rheumatoid arthritis: application of a validated algorithm to commercial insurance claims

PURPOSE

The aim of this analysis was to implement a claims-based algorithm to estimate biologic cost per effectively treated patient for biologics approved for moderate to severe rheumatoid arthritis (RA).

METHODS

This retrospective analysis included commercially insured adults (aged 18-63 years) with RA in a commercial database, who initiated biologic treatment with abatacept, adalimumab, etanercept, golimumab, or infliximab between 2007 and 2010. The algorithm defined effectiveness as having all of the following: high adherence, no biologic dose increase, no biologic switching, no new nonbiologic disease-modifying antirheumatic drug, no increased or new oral glucocorticoid use, and no more than 1 glucocorticoid injection. For each biologic, cost per effectively treated patient was defined as total drug and administration costs (from allowed amounts on claims), divided by the number of patients categorized as effectively treated.

FINDINGS

Of 15,351 patients, 12,018 (78.3%) were women, and the mean (SD) age was 49.7 (9.6) years. The algorithm categorized treatment as effective in the first year for 30% (1899/6374) of etanercept, 30% (1396/4661) of adalimumab, 20% (560/2765) of infliximab, 27% (361/1338) of abatacept, and 29% (62/213) of golimumab treated patients. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was nominally lower for subcutaneously injected biologics than for infused biologics. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was lowest for etanercept ($49,952), followed by golimumab ($50,189), adalimumab ($52,858), abatacept ($71,866), and infliximab ($104,333).

IMPLICATIONS

Algorithm-defined effectiveness was similar for biologics other than infliximab. The 1-year biologic cost per effectively treated patient, as defined by the algorithm, was nominally lower for subcutaneously injected biologics than for infused biologics.

Costs of tumor necrosis factor blockers per treated patient using real-world drug data in a managed care population

BACKGROUND

Several anti-inflammatory biologic medications are available in the United States for the treatment of moderate-to-severe rheumatoid arthritis, moderate-to-severe psoriasis, psoriatic arthritis, or ankylosing spondylitis. The tumor necrosis factor (TNF) blockers etanercept, adalimumab, and infliximab are approved for use in adults with any of these conditions, but predicting the annual costs of TNF-blocker treatment is complex due to differences in dosing schedules, treatment gaps, switching between TNF blockers, and dose escalation over time.

OBJECTIVES

To estimate the annual cost per treated patient from the payer perspective for etanercept, adalimumab, or infliximab in adults with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis.

METHODS

Adults in the IMS LifeLink Health Plan Claims Database were analyzed if they had at least 1 claim for etanercept, adalimumab, or infliximab between February 1, 2008, and July 5, 2010, and were continuously enrolled for at least 180 days before (pre-index period) through 360 days after the index claim (the first TNF-blocker claim after 6 months of continuous enrollment in the study period). Patients had a diagnosis of rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis, or a combination of these conditions, in the pre-index period. Cost was based on dose and price using April 2012 wholesale acquisition cost. Costs of administration were included for the first subcutaneous dose (etanercept or adalimumab) for new patients and for every intravenous dose (infliximab). Total TNF-blocker drug and administration costs, including nonindex TNF-blocker costs among patients who switched treatments, were divided by number of patients to yield cost per treated patient for each index TNF blocker. Subgroup analyses included cost by condition and cost for patients who were new to TNF-blocker treatment (no index TNF-blocker claim in the pre-index period) or continuing TNF-blocker treatment.

RESULTS

Of the 30,107 patients in the analysis, the majority received etanercept (15,488 patients; 51.4%), followed by adalimumab (8,959 patients; 29.8%) and infliximab (5,660 patients; 18.8%). Approximately 2 in 3 patients (18,897 patients) were continuing TNF-blocker treatment, including 66.0%, 52.6%, and 70.0% of patients in the etanercept, adalimumab, and infliximab groups, respectively. Across all indications, the annual TNF-blocker cost per treated patient was lowest for etanercept, followed by adalimumab and then infliximab, respectively: overall ($17,767, $19,272, and $24,273); new patients ($17,270, $17,959, and $21,482); and continuing patients ($18,203, $20,453, and $25,468). Cost by condition among all patients ranged from $14,838 to $20,251 for etanercept, from $18,051 to $20,233 for adalimumab, and from $22,939 to $28,519 for infliximab. Cost by condition was 3% to 31% greater for adalimumab than for etanercept (relative cost, 103% to 131%), except among patients with psoriasis (relative cost, 94%), and was 26% to 72% greater for infliximab than for etanercept (relative cost, 126% to 172%). Approximately 9% to 11% of patients in each group switched TNF blockers in the first year, and the costs of nonindex TNF blockers comprised 16.8% of the total cost for etanercept, 13.4% for adalimumab, and 6.9% for infliximab.

CONCLUSIONS

In adult patients with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis, or some combination of these conditions, etanercept had a lower cost per treated patient than adalimumab or infliximab, except in patients with psoriasis alone. In these patients, adalimumab had a lower cost per treated patient than etanercept or infliximab.

Annual acquisition and administration cost of biologic response modifiers per patient with rheumatoid arthritis, psoriasis, psoriatic arthritis, or ankylosing spondylitis

OBJECTIVE

To estimate annual biologic response modifier (BRM) cost per treated patient with rheumatoid arthritis, psoriasis, psoriatic arthritis, and/or ankylosing spondylitis receiving etanercept, abatacept, adalimumab, certolizumab, golimumab, infliximab, rituximab, or ustekinumab.

METHODS

This was a cohort study of 69,349 commercially insured individuals in a nationwide claims database with one of these conditions that had a claim for one of these BRMs between January 2008 and December 2010 (the index BRM/index date). Cost per treated patient was calculated as the total BRM acquisition and administration cost to the payer in the first year after the index date (including costs of other BRMs after switching) divided by the number of patients who received the index BRM. Etanercept was selected as the reference for comparisons.

RESULTS

Etanercept was the most commonly used index BRM (n = 32,298; 47%), followed by adalimumab (n = 20,582; 30%), infliximab (n = 11,157; 16%), abatacept (n = 2633; 4%), rituximab (n = 1359; 2%), golimumab (n = 687; <1%), ustekinumab (n = 388; <1%), and certolizumab (n = 245; <1%). Using etanercept as the reference, the cost per treated patient in the first year across all four conditions was 102% for adalimumab and 108% for infliximab. Newer BRMs had costs relative to etanercept that were 90% to 102% for rheumatoid arthritis, 132% for psoriasis, 100% for psoriatic arthritis, and 94% for ankylosing spondylitis.

LIMITATIONS

Potential study limitations were the lack of clinical information (e.g., disease severity, treatment outcomes) or indirect costs, the inability to compare costs of newer BRMs across all four conditions, and much smaller sample sizes for newer BRMs.

CONCLUSIONS

Of the BRMs that are approved for indications within all four conditions studied, etanercept had the lowest cost per treated patient when assessed across all four conditions.

Care coordination to increase referrals to smoking cessation telephone counseling: a demonstration project

OBJECTIVE

To test the effectiveness of a care coordination program for telephone counseling in raising referral and treatment rates for smoking cessation.

STUDY DESIGN

A demonstration project implementing a smoking cessation care coordination program offering telephone counseling and medication management to patients referred from primary care.

METHODS

The study was performed at 18 Veterans Health Administration (VA) sites in California. Participants were VA patients receiving primary care. We randomly allocated 10 of 18 sites to receive the Telephone Care Coordination Program, which included simple 2-click referral, proactive care coordination, medication management, and 5 follow-up telephone calls. Each patient received a 30- to 45-minute counseling session from the California Smokers' Helpline. Patients at control sites received usual care.

RESULTS

During 10 months, we received 2965 referrals. We were unable to reach 1156 patients (39%), despite at least 3 attempts. We excluded 73 patients (3%), and 391 patients (13%) were not interested. We connected the remaining 1345 patients (45%) to the Helpline. At 6-month followup, 335 patients (11% of all referrals and 25% of participating patients) were abstinent. Providers at intervention sites reported referring many more patients to telephone counseling than providers at control sites (15.6 vs 0.7 in the prior month).

CONCLUSIONS

The program generated a large number of referrals; almost half of the patients referred were connected with the Helpline. Long-term abstinence was excellent. These results suggest that managed care organizations may be able to improve tobacco control by implementing a similar system of care coordination.

Physicians' perceptions of relevant prescription drug costs: do costs to the individual patient or to the population matter most?

OBJECTIVES

Physicians may be aware of at least 2 types of costs when prescribing: patient's out-of-pocket costs and the actual costs of the medication. We evaluated physicians' perceptions about relevant costs for prescription drugs and the importance of communication about these costs.

STUDY DESIGN

Mailed survey to a random sample of 1200 physician members of the California Medical Association, and a phone survey of a sample of nonresponders.

METHODS

Descriptive statistics of survey items, McNemar's test to compare survey item responses, and logistic regression to evaluate the relationship between physician, practice, and system variables and physicians' perceptions of relevant medication costs.

RESULTS

Of respondents with correct addresses, 49.6% responded to the survey; 13% of nonresponders were contacted by phone. Approximately 91% and 80% of physicians reported that it is important to manage patients' out-of-pocket costs and total medication costs, respectively. When comparing the relative importance of managing the 2 types of costs, 59% of physicians agreed that managing patients' out-of-pocket costs was more important than managing the total medication costs and only 16% disagreed. Physicians believed it was more important to discuss out-of-pocket costs than total costs with patients (P < .0001), but only 15% of physicians reported discussing out-of-pocket costs frequently and 5% reported talking about total medication costs frequently. Physicians who managed more Medicare patients had a greater likelihood than physicians managing fewer Medicare patients of prioritizing out-of-pocket cost rather than total cost management (P = .038), and generalists had a greater likelihood than medical subspecialists (P = .046).

CONCLUSIONS

Physicians prioritize managing out-of-pocket costs over total medication costs. Pharmacy benefit designs that use patient out-of-pocket cost incentives to influence utilization are addressing the costs to which physicians may be most responsive. When physicians face conflicts between managing patients' out-of-pocket costs and total costs, they will likely try to protect the patients' resources at the expense of the insurer or society. Efforts to align patients', insurers', and societies' incentives will simplify prescribing decisions and result in better value in prescribing.

Physicians' perceived knowledge of and responsibility for managing patients' out-of-pocket costs for prescription drugs

BACKGROUND

Most insurers in the US have implemented incentive-based formularies that rely on out-of-pocket costs to influence prescription drug utilization. Medicare Part D plans have broadly adopted such benefit designs.

OBJECTIVE

To evaluate physicians' perceptions of their knowledge of formularies and out-of-pocket costs, factors that influence knowledge of costs, physicians' perceived responsibility for helping patients manage their out-of-pocket costs for prescription drugs, and physicians' perceptions of the role of pharmacists in managing these costs.

METHODS

A multiple-choice survey was mailed to a random sample of 1200 physician members of the California Medical Association; a phone survey of nonresponders was then conducted.

RESULTS

Of 1027 surveys delivered to correct addresses, 509 (49.6%) responses were received. Thirty-three percent of physicians reported that they were usually or always aware of patients' formularies and 20% were usually or always aware of patients' out-of-pocket costs for medications. Surgeons, emergency department physicians, and physicians that prescribe from more formularies than other physicians are less likely to be aware of patients' out-of-pocket costs, while physicians in large practices and those who use computers to prescribe are more aware. While 91% of physicians agreed that it is important that patients' out-of-pocket costs be managed, 40% somewhat or strongly agreed that it is their responsibility to help. Sixty-five percent of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs.

CONCLUSIONS

Physicians often lack the knowledge to assist patients in the management of their out-of-pocket costs for prescription drugs and they depend on pharmacists to help patients manage those costs. Computer order entry and resources available in large physician organizations improve physicians' awareness of out-of-pocket costs when prescribing.

Pharmacy data in the VA health care system

Recent advances in Department of Veterans Affairs (VA) health care data systems have greatly increased access to operational pharmacy information. This article presents a brief guide to VA pharmacy data sources: the Veterans Health Information Systems and Technology Architecture files, the Pharmacy Benefits Management database, Decision Support System (DSS) National Data Extracts for inpatient and outpatient care, the planned DSS National Pharmacy Extract, DSS databases at local VA facilities, and the Non-VA Fee Basis files. Depending on the source, available data elements include patient demographics, clinical care information, characteristics of the medication and of the prescribing physician, and cost. Access policies are detailed for VA and non-VA researchers. Linking these sources to VA databases containing data on inpatient and outpatient services offers a comprehensive view of health care within several VA populations of general interest, including people over age 65 and those with physical and psychiatric disabilities.

Using the Veterans Health Administration inpatient care database: trends in the use of antireflux surgery

Context. In the private sector, the use of surgery to treat gastroesophageal reflux disease has increased substantially since the development of minimally invasive laparoscopic techniques. However, trends in the use of antireflux surgery in the Veterans Affairs (VA) health care system have not been explored. Objective. To compare secular trends in the use of antireflux surgery in VA hospitals and the private sector. Data Sources. VA data are from the 1991-1999 medical SAS datasets for inpatient care (commonly known as patient treatment files); private sector data are from the 1991-1997 Nationwide Inpatient Sample and the U.S. census. Calculations. We compared secular trends in the use of antireflux surgery in the VA and private sector with each group's baseline rate in 1991. For the VA, we calculated annual rates of antireflux surgery among active users of the VA health care system by dividing the number of procedures (based on the appropriate procedure codes from the International Classification of Diseases, ninth revision, clinical modification) by the number of veterans who had at least two hospital or clinic visits in a given year. For the private sector, we calculated true population rates by dividing procedure counts by the total U.S. population. Results. From 1991 to 1995, the annual rate of antireflux surgery among active users of VA hospitals increased by 64%, then decreased over the next 4 years to almost baseline rates. In contrast, rates of antireflux surgery in the private sector increased 185% from 1991 to 1995, then appeared to reach a plateau thereafter. Among patients undergoing antireflux surgery, those in the VA were less likely than those in the private sector to undergo laparoscopic surgery (29% vs. 65%, respectively, in 1997). Conclusions. With the development of laparoscopic surgery, rates of antireflux surgery in VA hospitals increased only modestly compared with the private sector and have decreased in recent years. Both patient and provider factors may explain the substantially higher use of this procedure in the private sector.

Abciximab rescue in acute carotid stent thrombosis

Occlusion of an internal carotid artery stent was identified immediately post placement in a patient who had restenosis after prior angioplasty. An IV dose of abciximab was administered, and serial angiograms were performed. This resulted in partial resolution of the thrombus at 10 minutes and complete resolution at 20 minutes.

Use of three-dimensional Guglielmi detachable coils in the treatment of wide-necked cerebral aneurysms

A three-dimensional Guglielmi detachable coil (3D-GDC) has been developed that is designed specifically to bridge the neck of an aneurysm with coil loops, thereby facilitating retention of additional coils placed within the aneurysm. Nine wide-necked cerebral aneurysms were successfully embolized using the 3D-GDC, provided that the dome-to-neck ratio was 1.5 or greater.

A standardized method for measuring intracranial arterial stenosis

BACKGROUND AND PURPOSE

Atherosclerosis of the major intracranial arteries is an important cause of ischemic stroke. We established measurement criteria to assess percent stenosis of a major intracranial artery (carotid, middle cerebral, vertebral, basilar) and determined the interobserver/intraobserver agreements and interclass/intraclass correlations of these measurements.

METHODS

We defined percent stenosis of an intracranial artery as follows: percent stenosis = [(1 - (D(stenosis)/D(normal)))] x 100, where D(stenosis) = the diameter of the artery at the site of the most severe stenosis and D(normal) = the diameter of the proximal normal artery. If the proximal segment was diseased, contingency sites were chosen to measure D(normal): distal artery (second choice), feeding artery (third choice). Using a hand-held digital caliper, three neuroradiologists independently measured D(stenosis) and D(normal) of 24 stenotic intracranial arteries. Each observer repeated the readings 4 weeks later. We determined how frequently two observers' measurements of percent stenosis of each of the 24 diseased arteries differed by 10% or less.

RESULTS

Among the three pairs of observers, interobserver agreements were 88% (observer 1 versus observer 2), 79% (observer 1 versus observer 3), 75% (observer 2 versus observer 3) for the first reading and were 75% (observer 1 versus observer 2), 100% (observer 1 versus observer 3), and 71% (observer 2 versus observer 3) for the second reading. Intraobserver agreement for each of the observers was 88%, 83%, and 100%. Interclass correlation was 85% (first reading) and 87% (second reading). Intraclass correlation was 92% (first and second readings combined).

CONCLUSION

This method shows good interobserver and intraobserver agreements for the measurement of intracranial stenosis of a major artery. If validated in subsequent studies, this method may serve as a standard for the measurement of percent stenosis of an intracranial artery.

Prevention of complications resulting from endovascular carotid sacrifice: a retrospective assessment

OBJECTIVE

To determine the protective effects of various periprocedural interventions in the prevention of cerebral ischemia as a complication of endovascular carotid sacrifice (ECS).

METHODS

Thirty-two cases of ECS performed at our institution, between October 1987 and July 1998, were reviewed. Fifteen patients underwent superficial temporal artery-to-middle cerebral artery bypass surgery. In 21 patients, the carotid artery was occluded proximal to the target lesion; and in 11 patients, a lesion trapping procedure was performed. Six patients were prophylactically anticoagulated, 14 received antiplatelet agents prophylactically, and 12 received no pharmacoprophylaxis.

RESULTS

Among the six patients who were anticoagulated, there were no embolic events. Embolic events affected 4 of 14 patients receiving prophylactic antiplatelet agents, 2 of 12 patients receiving no pharmacoprophylaxis, 1 of 11 patients who underwent a trapping procedure, and 5 of 21 patients whose carotid artery was occluded proximal to the target lesion. Postocclusion cerebral ischemia developed in 7 of 15 patients who underwent bypass surgery, and in 1 of the remaining 17.

CONCLUSION

Superficial temporal artery-to-middle cerebral artery bypass did not protect against postocclusion cerebral ischemia after ECS in this series (P = 0.01). Although the small number of patients studied precludes statistical validity (P = 0.29), the trends suggest that antiplatelet agents provide no protection against postocclusion cerebral emboli after ECS. Prophylactic anticoagulation (P = 0.32) and lesion trapping (P = 0.12) may reduce the frequency of postocclusion embolic events after ECS; however, because of the small number of patients, statistical significance could not be demonstrated.

Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis

BACKGROUND AND PURPOSE

A well-defined complication rate of cerebral angiography in patients with subarachnoid hemorrhage (SAH), cerebral aneurysm, and arteriovenous malformation (AVM) would be useful to physicians making decisions regarding the imaging of these patients. We sought to define a statistically significant complication rate through meta-analysis of prospective studies in the literature.

METHODS

Meta-analysis of 3 published prospective studies of complications in cerebral angiography was performed to specifically define the risk of cerebral angiography in patients presenting with SAH, cerebral aneurysm, and AVM. The complication rates for cerebral angiography in patients with SAH and AVM/aneurysm without SAH were compared with the complication rates in patients who underwent cerebral angiography for transient ischemic attack (TIA)/ischemic stroke with use of the Fisher exact test.

RESULTS

The combined risk of permanent and transient neurological complication was significantly lower in patients with SAH compared with patients with TIA/stroke (1.8% versus 3.7%; P=0.03). The combined risk of permanent and transient neurological complication was significantly lower in patients with aneurysm/AVM without SAH compared with patients with TIA/stroke (0.3% versus 3.7%; P=0.001). When the patients with SAH and cerebral aneurysm/AVM were combined, the overall risk of permanent and transient neurological complication was significantly lower than for the TIA/stroke patients (0.8% versus 3.0%; P=0.001), as was the risk of permanent neurological complication (0.07% versus 0.7%; P=0.004).

CONCLUSIONS

The risk of permanent neurological complication associated with cerebral angiography in patients with SAH, cerebral aneurysm, and AVM is quite low (0.07%). This risk is lower than previously recognized.

Transvenous embolization as the primary therapy for arteriovenous fistulas of the lateral and sigmoid sinuses

PURPOSE

We report on the evolution in one institution from transarterial embolization for the treatment of dural arteriovenous fistulas of the lateral and sigmoid sinuses to the safer and more durable technique of transvenous endovascular therapy for the majority of these lesions.

METHODS

Arterial, venous, and combined embolizations were performed for 24 fistulas of the lateral and sigmoid sinuses between August 1991 and December 1996. The patients were followed up clinically for 2 to 63 months, with a mean follow-up period of 30 months.

RESULTS

Nine patients had arterial embolization without transvenous treatment: five of the nine had angiographic and clinical obliteration of their fistulas; two of the nine, with unusual lesions, required surgery; and the remaining two had recurrences and were not retreated. Seven patients had both arterial embolization and coil embolization (packing) of the dural sinuses, four after arterial embolization had failed to cure the lesions; in all seven, the fistulas were obliterated angiographically and clinically. Eight patients had only transvenous coil embolization of the dural sinuses; all eight were cured. One patient had minimal arterial embolization during the primary venous embolization procedure. Complications occurred in two patients, both related to arterial embolization with ethanol.

CONCLUSION

Our experience suggests that arterial embolization of dural arteriovenous fistulas of the lateral and sigmoid sinuses is associated with a low cure rate and high rate of recurrence, whereas transvenous endovascular packing of the involved segment of the sinus results in a high cure rate that obviates arterial embolization or surgical excision in most cases.

Tacrolimus (FK506)-induced cerebral blindness following bone marrow transplantation

Three patients who developed acute onset of cerebral blindness within 5-47 days of BMT using tacrolimus (FK506) as primary GVHD prophylaxis are described. This syndrome has been described with the use of cyclosporin A (CsA) and FK506 in solid organ transplant recipients. CsA-induced cerebral blindness has also been noted in BMT recipients but to date there have been no reports of this complication in BMT patients receiving FK506. We have noted a striking similarity in the clinical and radiographic presentations between these patients and those with CsA-associated cerebral blindness. Reversibility within 1-2 weeks of onset and the potential for substitution of CsA for FK506 in these patients is described.

Intracranial adenoid cystic carcinoma: case report and review of the literature

BACKGROUND

Adenoid cystic carcinoma (cylindroma) is a relatively common head and neck tumor that is slow growing, but locally aggressive and thus prone to recurrence. It is of particular interest to neurosurgeons and neurologists because of its tendency to locally infiltrate neural structures and to spread perineurally. Intracranial involvement has been regarded as rare.

METHODS

A case report of a patient with adenoid cystic carcinoma involving the Gasserian ganglion region is presented. The world literature on intracranial involvement of adenoid cystic carcinoma is reviewed. A discussion of the characteristics of this lesion is provided.

RESULTS

Our literature review revealed 119 previously reported cases of adenoid cystic carcinoma with intracranial involvement. Our case represents only the tenth reported intracranial case with an unknown primary site.

CONCLUSIONS

Although intracranial adenoid cystic carcinoma is regarded as rare, we have accumulated over 100 such reports. A wide variety of primary sites and intracranial sites have been described.

Treatment of experimental aneurysms using collagen-coated microcoils

Endovascular treatment of certain surgically difficult aneurysms is currently performed using fibered microcoils or electrolytically detachable microcoils to obliterate these lesions by forming an intra-aneurysmal thrombus. Unfortunately, this treatment option results in a significant incidence of incomplete obliteration of treated aneurysms. A thrombus can recanalize, resulting in further aneurysm growth and subsequent rupture. Nineteen aneurysms were surgically created in 10 pigs using jugular venous pouches. The aneurysms were allowed to mature for periods of 7 days to as long as 11 weeks prior to embolization. Fourteen remained patent for embolization. The aneurysms were then embolized (9 with collagen-coated microcoils, 5 with dacron-fibered platinum microcoils). Follow-up angiograms were obtained prior to sacrifice at 1, 3, 6, 9, and 12 weeks postembolization, and the embolized aneurysms and parent vessels were harvested for histopathological studies. The current study was designed to evaluate the potential efficacy of collagen-coated microcoils in providing an enduring therapy for aneurysms by comparing this new embolic device with the standard dacron-fibered platinum microcoils in a swine common carotid artery side wall aneurysm model. The aneurysms treated with collagen microcoils were completely obliterated with a collagen-rich fibrous scar with no histological evidence of residual thrombus or recanalization. Additionally, after treatment of experimental aneurysms with collagen microcoils, re-endothelialization across the former aneurysm neck was seen. In contrast, aneurysms embolized with dacron-fibered microcoils contained persistent thrombus surrounded by a relatively immature scar with residual aneurysmal lumen and lack of endothelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined extracranial-intracranial bypass and intraoperative balloon occlusion for the treatment of intracavernous and proximal carotid artery aneurysms

A protocol for the treatment of selected intracavernous and proximal internal carotid artery aneurysms is described. Intraoperative angiography is used together with intraoperative balloon occlusion of the internal carotid artery and electroencephalography to optimize the timing of an extracranial-intracranial bypass before occlusion of the carotid artery and to provide intraoperative documentation of graft patency. This protocol has been used successfully in seven patients with complex aneurysms that were unsuitable for other endovascular methods or a direct microsurgical approach. Six aneurysms were located in the cavernous sinus, and one was located on the supraclinoid portion of the internal carotid artery. There were no permanent complications; one patient had a brief episode of dysphasia, which resolved without sequelae.

Comparison of full- and half-dose gadolinium-DTPA: MR imaging of the normal sella

PURPOSE

This study compares sellar intensities in 17 patients without sellar pathology using half (0.05 mmol/kg, nine patients) and full-dose (0.1 mmol/kg, eight patients) gadopentetate dimeglumine (Gd-DTPA).

METHODS

Sellar MR studies of eight patients who received full and nine patients who received half-dose Gd-DTPA were compared, retrospectively. Sequences included pre-, immediate, and delayed postcontrast T1-weighted coronal images (1.5 T). Intensity measurements were obtained by two observers using a uniform region of interest.

RESULTS

Comparison of normalized intensities revealed no significant difference between intensities obtained from immediate half- and full-dose techniques for any of the tissues examined (Student's t test, P < .90). Delayed scans likewise demonstrated no significant intensity differences between full- and half-dose studies.

CONCLUSION

Our findings suggest that a 50% reduction in dosage of Gd-DTPA for sellar MR at 1.5 T results in no significant diminution in intensity of enhancement of the pituitary gland or adjacent tissues.

Intraoperative angiography in the management of neurovascular disorders

Intraoperative angiography is useful in verifying the goals of neurovascular operations during the procedure and before the wound is closed. We report on our technique of intraoperative angiography in 115 neurovascular operations, including obliteration of intracranial aneurysms, resection of brain and spinal arteriovenous malformations, creation of extracranial-to-intracranial bypass grafts, and carotid endarterectomy. Of these 115 procedures, intraoperative angiograms provided information that altered the operative procedure on 19 occasions. There were two complications in the 115 cases that may be related to the intraoperative angiographic procedure. Overall, however, the quality of image provided by portable digital subtraction intraoperative angiography makes this technique a safe adjunct to neurovascular surgery.

Pituitary adenoma: correlation of half-dose gadolinium-enhanced MR imaging with surgical findings in 26 patients

Sellar magnetic resonance imaging studies obtained with half doses of gadopentetate dimeglumine (0.05 mmol/kg) were prospectively interpreted and retrospectively rated in 26 patients who subsequently underwent transsphenoidal sellar surgery for suspected pituitary adenoma. Studies included a sagittal scout view followed by a non-contrast-material-enhanced, an immediate postcontrast, and a delayed postcontrast T1-weighted image (obtained at 1.0 or 1.5 T). Ten of 11 confirmed microadenomas were identified prospectively; all were identifiable in retrospect. Macroadenomas (12 cases) were well demonstrated. The high signal intensity of the posterior pituitary and of intrasellar hemorrhage was obscured on postcontrast studies. Delayed images proved unnecessary. This prospective evaluation suggests that a half-dose study is comparable to retrospective studies in which full-dose techniques were used for detection of micro- and macroadenomas. Imaging times are reasonably short, and cost of contrast material is potentially reduced. Confirmation with larger studies is required, and careful endocrinologic and clinical follow-up of nonsurgical patients is necessary.

Double-guide-wire access through a single 6-F vascular sheath

Three techniques are described that employ double-guide-wire access through a single vascular sheath in the common femoral artery. One technique provides arterial side branch protection during balloon angioplasty of stenotic vascular branch points. Another maintains guide wire access within a dilated renal artery while postangioplasty aortography is performed. A third technique achieves superficial femoral artery access during antegrade femoral artery puncture.

Patterns of gastroesophageal reflux in health and disease

Twenty-four pH monitoring the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studies with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic pateitns with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.