Radiofrequency ablation using the ThermoCool SmartTouch Catheter guided by ablation index versus antiarrhythmic drugs in atrial fibrillation treatment in China: a cost-consequence analysis

Aim: To evaluate the costs and consequences of two front-line atrial fibrillation (AF) treatments from Chinese healthcare system perspective: radiofrequency catheter ablation (RFCA) using ThermoCool SmartTouch Catheter guided by Ablation Index (STAI), in comparison to antiarrhythmic drugs (AADs). Patients & methods: We simulated clinical and economic consequences for AF patients initially receiving STAI or AADs using a short-term decision tree model leading to a 10-year long-term Markov model. The model projected both clinical consequences and costs associated with, among others, AF, heart failure (HF), strokes, and deaths due to AF or AF related complications. Data informing the models included combination of a local real-world study and published clinical studies. Results: STAI was advantageous versus AADs on all 4 main clinical outcomes evaluated; AF: 25.83% lower (12.84% vs 38.67%), HF: 2.22% lower (1.33% vs 3.55%), stroke or post stroke: 1.82% lower (10.00% vs 11.82%) and deaths due to AF or AF related complications: 0.64% lower (4.11% vs 4.75%). The average total cost per patient in STAI group was ¥16,682 lower (¥123,124 vs ¥139,806). The one-way sensitivity analysis indicated that the difference in total cost was most sensitive to annual AF recurrence probability in AADs-treated patients. Probabilistic sensitivity analysis indicated a 98.5% probability that RFCA treatment would result in cost savings by the end of the 10th year. Conclusion: Radiofrequency catheter ablation using SmartTouch catheter guided by Ablation Index was superior to AADs as the first-line AF treatment in Chinese setting with better clinical outcomes and at lower costs over a 10-year time horizon.

Cost-Effectiveness Analysis of Relmacabtagene Autoleucel for Relapsed or Refractory Large B-Cell Lymphoma in China

OBJECTIVES

Relmacabtagene autoleucel (relma-cel) was recently approved in China for treating relapsed or refractory large B-cell lymphoma (r/r LBCL). We conducted a cost-effectiveness analysis from the perspective of Chinese healthcare system.

METHODS

A mixture-cure model was developed to project life-years (LYs), quality-adjusted LYs (QALYs), and overall direct cost with a lifetime horizon for patients with r/r LBCL treated with relma-cel versus salvage chemotherapy. Patient-level data from RELIANCE trial and published data from Collaborative Trial in Relapsed Aggressive Lymphoma extension study were used to inform the model. The incremental cost-effectiveness ratio (ICER) was estimated and cost-effectiveness was evaluated at the willingness-to-pay threshold of 3 times the national gross domestic product per capita.

RESULTS

The model projected that treatment with relma-cel was associated with incremental gains of 5.11 LYs and 5.26 QALYs compared with salvage chemotherapy at an increased cost of ¥1 067 430 (∼$154 152), resulting in an ICER of ¥203 137 (∼$29 435) per QALY. The model was most sensitive to the uncertainty around the estimated cure rate. The ICER of relma-cel was within the willingness-to-pay threshold in the base case and the probability of relma-cel treatment being considered cost-effective was approximately 74%.

CONCLUSIONS

Compared with salvage chemotherapy, treatment with relma-cel for r/r LBCL in patients who have failed at least 2 lines of systemic therapy is within the cost-effective range from the perspective of Chinese healthcare system and represents a good use of healthcare resources.

Association of statin use and increase in lipoprotein(a): a real-world database research

BACKGROUND

There is an increased concern that statins may have an unintended effect of elevated lipoprotein(a) [Lp(a)]. We conducted a large sample real-world study to test the association.

METHODS

This retrospective cohort study was conducted using data from an integrated SuValue database, which includes 221 hospitals across China covering more than 200,000 of population with longitudinal follow-up to 10 years. Propensity score matching was applied to identify two comparable cohorts with statin users and non-statin users. Detailed follow-up information such as Lp(a) levels were extracted. The hazard ratio was calculated on Lp(a) changes based on the statin usage cohorts. Detailed subgroup and different characteristic cohorts' analyses were also conducted.

RESULTS

After baseline propensity score matching, a total of 42,166 patients were included in a 1:1 matched ratio between statin users and non-statin users. In the case of no difference in low density lipoprotein (LDL-C), Lp(a) was increased significantly with the use of statins (adjusted HR 1.47; 95% confidence interval [CI] 1.43-1.50). Lp(a) increase was observed in various subgroup analyses and different cohorts. The dose intensity of statin was positively associated with the evaluated Lp(a) level.

CONCLUSION

The use of statins was associated with an increased risk of Lp(a) elevation compared with non-statin use counterparts. The clinical relevance of these increases needs to be addressed in surrogate marker trials and/or large, cardiovascular outcomes trials.

Access to innovative drugs and the National Reimbursement Drug List in China: Changing dynamics and future trends in pricing and reimbursement

BACKGROUND AND OBJECTIVES

Multiple reforms aimed at improving the Chinese population's health have been introduced in recent years, including several designed to improve access to innovative drugs. We sought to review current factors affecting access to innovative drugs in China and to anticipate future trends.

METHODS

Targeted reviews of published literature and statistics on the Chinese healthcare system, medical insurance and reimbursement processes were conducted, as well as interviews with five Chinese experts involved in the reimbursement of innovative drugs.

RESULTS

Drug reimbursement in China is becoming increasingly centralized due to the removal of provincial pathways, the establishment of the National Healthcare Security Administration and the implementation of the National Reimbursement Drug List (NRDL), which is now the main route for drug reimbursement in China. There is also an increasing number of other channels via which patients may access innovative treatments, including various types of commercial insurance and special access. Health technology assessment (HTA) and health economic evidence are becoming pivotal elements of the NRDL decision-making process. Alongside the optimization of HTA decision making, innovative risk-sharing agreements are anticipated to be increasingly leveraged in the future to optimize access to highly specialized technologies and encourage innovation while safeguarding limited healthcare funds.

CONCLUSIONS

Drug public reimbursement in China continues to align more closely with approaches widely used in Europe in terms of HTA, health economics and pricing. Centralization of decision-making processes for public reimbursement of innovative drugs allows consistency in assessment and access, which optimizes the improvement of the Chinese population's health.

Fine and coarse particulate air pollution and hospital admissions for a wide range of respiratory diseases: a nationwide case-crossover study

BACKGROUND

The associations between fine and coarse particulate matter (PM2.5 and PM2.5-10) air pollution and hospital admissions for full-spectrum respiratory diseases were rarely investigated, especially for age-specific associations. We aim to estimate the age-specific associations of short-term exposures to PM2.5 and PM2.5-10 with hospital admissions for full-spectrum respiratory diseases in China.

METHODS

We conducted an individual-level case-crossover study based on a nationwide hospital-based registry including 153 hospitals across 20 provincial regions in China in 2013-20. We applied conditional logistic regression models and distributed lag models to estimate the exposure- and lag-response associations.

RESULTS

A total of 1 399 955 hospital admission records for various respiratory diseases were identified. The associations of PM2.5 and PM2.5-10 with total respiratory hospitalizations lasted for 4 days, and an interquartile range increase in PM2.5 (34.5 μg/m3) and PM2.5-10 (26.0 μg/m3) was associated with 1.73% [95% confidence interval (95% CI): 1.34%, 2.12%)] and 1.70% (95% CI: 1.31%, 2.10%) increases, respectively, in total respiratory hospitalizations over lag 0-4 days. Acute respiratory infections (i.e. pneumonia, bronchitis and bronchiolitis) were consistently associated with PM2.5 or PM2.5-10 exposure across different age groups. We found the disease spectrum varied by age, including rarely reported findings (i.e. acute laryngitis and tracheitis, and influenza) among children and well-established associations (i.e. chronic obstructive pulmonary disease, asthma, acute bronchitis and emphysema) among older populations. Besides, the associations were stronger in females, children and older populations.

CONCLUSIONS

This nationwide case-crossover study provides robust evidence that short-term exposure to both PM2.5 and PM2.5-10 was associated with increased hospital admissions for a wide range of respiratory diseases, and the spectra of respiratory diseases varied by age. Females, children and older populations were more susceptible.

The impact of preloaded intraocular lens implantation system (TECNIS iTec®) in routine cataract surgery in China: a time-motion analysis

OBJECTIVE

To evaluate the impact on surgical efficiency and labor time cost of preloaded intraocular lens (IOL) implantation system compared with manual IOL implantation system in age-related cataract surgery in China.

METHODS

This study was an observational, multicenter, prospective time-motion analysis. IOL preparation time, operation time, cleaning time, number and cost of cataract surgeries in eight participating hospitals were collected. The linear mixed model was used to explore factors associated with the difference in operation time between the preloaded IOL implantation system and the manual IOL implantation system. A time-motion model was constructed to convert the operation time cost saved by using preloaded IOL into economic benefits from hospital and social perspective, respectively.

RESULTS

There were 2,591 cases included in the study (preloaded IOL: 1,591 cases; manual IOL: 1,000 cases). The preloaded IOL implantation system was significant time-saving in both preparation time and operation time compared to the manual IOL implantation system (25.48s vs. 47.04s, P < 0.001 and 353.84s vs. 367.46s, P = 0.004, respectively). An average total of 35.18s can be saved by using preloaded IOL per procedure. The results of linear mixed model showed that the type of IOL was the main factor leading to the difference in preparation time between preloaded IOL and manual IOL implantation system. By switching from manual IOL to preloaded IOL, the model projected additional 392 surgeries can be performed each year and an increase in revenue of $565,282 per hospital, a 9% increase from hospital perspective. And the annual productivity loss saved by using preloaded IOL was $3,006 in eight hospitals from perspective of society.

CONCLUSION

Compared with manual IOL implantation system, the preloaded IOL implantation system reduces lens preparation time and operation time, which increases potential surgical volume and revenue, and reduces the loss of work productivity. This study provides real-world evidence to support the advantages of the preloaded IOL implantation system in improving efficiency of ophthalmic surgery in China.

A Cost-effectiveness Analysis of iGlarLixi Versus IDegAsp and Appropriate Price Exploration of iGlarLixi for Type 2 Diabetes Mellitus Patients in China

BACKGROUND AND OBJECTIVE

The efficacy and safety of iGlarLixi, a fixed-ratio combination (FRC) of basal insulin glargine plus lixisenatide, have been demonstrated in type 2 diabetes mellitus (T2DM) patients. However, no relevant economic analysis of iGlarLixi has been done in China. Thus, the primary objective of this study is to evaluate the cost effectiveness of iGlarLixi versus IDegAsp in Chinese T2DM patients, and then back-calculate the appropriate drug price of iGlarLixi to support its pricing after listing in China.

METHODS

The United Kingdom Prospective Diabetes Study Outcome Model 2 (UKPDS OM2) was applied to estimate lifetime health and economic outcomes from the Chinese health-care system perspective. As no head-to-head comparison data are currently available, the baseline cohort characteristics and the initial clinical data for iGlarLixi were derived from the randomized LixiLan-L-China trial. The relative treatment effects for IDegAsp were based on an indirect treatment comparison. Due to the unavailability of iGlarLixi pricing data, the annual medication cost of iGlarLixi was assumed to be equal to that of IDegAsp at the beginning of the study. Afterwards, a break-even analysis using comparator drug price and the willingness-to-pay (WTP) threshold was performed to back-calculate the appropriate drug price of iGlarLixi. One-way sensitivity analysis, scenario analysis and probabilistic sensitivity analysis (PSA) were conducted to assess the robustness of the model.

RESULTS

Based on the initial assumption of equal annual medication cost of iGlarLixi and IDegAsp, iGlarLixi was cost effective compared to IDegAsp with an incremental cost-effectiveness ratio (ICER) far below the WTP threshold in Chinese T2DM patients. From the back calculation for the price of iGlarLixi, the annual medication cost of iGlarLixi was $656.96 and $1075.96 to obtain an ICER of iGlarLixi versus IDegAsp close to 1 × GDP and 3 × GDP, respectively. When the discount rate was changed from the base value to 8% (the most sensitive parameter to the model results in one-way sensitivity analysis), the ICER was nearly equal to 1 × GDP and 3 × GDP with the annual medication cost of iGlarLixi decreasing to $590.41 and $865.03, respectively. Thus, iGlarLixi was dominant over IDegAsp with an annual medication cost of $590.41 to $865.03. The findings were robust to one-way sensitivity analysis, PSA and scenario analysis.

CONCLUSION

This long-term cost-effectiveness analysis in Chinese T2DM patients indicates that iGlarLixi, assuming equal price to IDegAsp, is cost-effective versus IDegAsp with an ICER far below the WTP threshold. With 1 × GDP and 3 × GDP threshold set we back-calculate the appropriate annual medication cost of iGlarLixi to be $590.41 to $865.03, respectively.

Evaluation of COVID-19 vaccines in primary prevention against infections and reduction in severity of illness following the outbreak of SARS-CoV-2 omicron variant in Shanghai

Objectives

To evaluate COVID-19 vaccines in primary prevention against infections and lessen the severity of illness following the most recent outbreak of the SARS-CoV-2 Omicron variant in Shanghai.

Data sources

Data from 153,544 COVID-19 patients admitted to the Shanghai "Four-Leaf Clover" Fangcang makeshift shelter hospital were collected using a structured electronic questionnaire, which was then merged with electronic medical records of the hospital. For healthy controls, data on vaccination status and other information were obtained from 228 community-based residents, using the same structured electronic questionnaire.

Methods

To investigate whether inactivated vaccines were effective in protecting against SARS-CoV-2 virus, we estimated the odds ratio (OR) of the vaccination by comparing cases and matched community-based healthy controls. To evaluate the potential benefits of vaccination in lowering the risk of symptomatic infection (vs. asymptomatic), we estimated the relative risk (RR) of symptomatic infections among diagnosed patients. We also applied multivariate stepwise logistic regression analyses to measure the risk of disease severity (symptomatic vs. asymptomatic and moderate/severe vs. mild) in the COVID-19 patient cohort with vaccination status as an independent variable while controlling for potential confounding factors.

Results

Of the 153,544 COVID-19 patients included in the analysis, the mean age was 41.59 years and 90,830 were males (59.2%). Of the study cohort, 118,124 patients had been vaccinated (76.9%) and 143,225 were asymptomatic patients (93.3%). Of the 10,319 symptomatic patients, 10,031 (97.2%), 281 (2.7%), and 7 (0.1%) experienced mild, moderate, and severe infections, respectively. Hypertension (8.7%) and diabetes (3.0%) accounted for the majority of comorbidities. There is no evidence that the vaccination helped protect from infections (OR = 0.82, p = 0.613). Vaccination, however, offered a small but significant protection against symptomatic infections (RR = 0.92, p < 0.001) and halved the risk of moderate/severe infections (OR = 0.48, 95% CI: 0.37-0.61). Older age (≥60 years) and malignant tumors were significantly associated with moderate/severe infections.

Conclusion

Inactivated COVID-19 vaccines helped provide small but significant protection against symptomatic infections and halved the risk of moderate/severe illness among symptomatic patients. The vaccination was not effective in blocking the SARS-CoV-2 Omicron Variant community spread.

Ambient heat stress and urolithiasis attacks in China: Implication for climate change

BACKGROUND

Although the existing studies have suggested a significant association between high temperatures and urolithiasis, no nationwide studies have quantified the burden attributable to environmental heat stress and explored how the urolithiasis burden would vary in a warming climate.

METHODS

We collected data on urolithiasis attacks from 137 hospitals in 59 main cities from 20 provincial regions of China from 2000 to 2020. An individual-level case-crossover analysis was conducted to estimate the effect of daily wet-bulb globe temperature (WBGT), a heat stress index combining temperature and humidity, on urolithiasis attacks. Stratified analyses were performed by region, age, and sex. We further quantified the future WBGT-related burden of urolithiasis from the Coupled Model Intercomparison Project Phase 6 under three Shared Socioeconomic Pathway (SSP) scenarios.

RESULTS

In total, 118,180 urolithiasis patients were evaluated. The exposure-response curve for the association between WBGT and urolithiasis attacks was J-shaped, with a significantly increased risk for WBGT higher than 14.8 °C. The middle-aged and elderly group (≥45 years old) had a higher risk of WBGT-related urolithiasis attacks than in the younger group, while no significant sex difference was observed. The attributable fraction (AF) due to high WBGT would increase from 10.1% in the 2010s to 16.1% in the 2090s under the SSP585 scenario. Warm regions were projected to experience disproportionately higher AFs and larger increments in the future.

CONCLUSIONS

This nationwide investigation provides novel evidence on the acute effect of high WBGT on urolithiasis attacks and demonstrates the increasing disease burden in a warming climate.

Clinical and economic benefits of image-guided system in functional endoscopicsinus surgery: a retrospective chart review study in China

BACKGROUND

Image-guided system (IGS) has been gradually applied in the field of rhinology, making functional endoscopic sinus surgery (FESS) a truly minimally invasive and precise surgery. This study was based on real-world data from China hospitals and aimed to evaluate the clinical and economic benefits of the IGS navigation system in FESS.

METHODS

This was a two-center retrospective chart review of patients with chronic rhinosinusitis who underwent FESS, including open frontal sinus between July 1, 2018 and December 31, 2019 in China. The intervention group consisted of 100 patients who underwent FESS with the IGS navigation system (IGS group), and the control group consisted of 100 patients who underwent conventional FESS (Non-IGS group). Data were collected from surgical notes and hospital medical records. The primary endpoints for clinical effectiveness and safety were avoid rehospitalization due to bleeding, avoid reoperation due to bleeding, and avoid reoperation due to recurrence.

RESULTS

There were no cases of rehospitalization due to bleeding, reoperation due to bleeding, and reoperation due to recurrence in the IGS group, with an avoidance rate of 100%. In the non-IGS group, there were four cases of rehospitalization and reoperation due to bleeding, with an avoidance rate 96.00% (P = 0.121). No cases of reoperation due to recurrence were in the non-IGS group. The total hospitalization cost was 17,391.51 CNY in the IGS group and 17,742.41 CNY in the non-IGS group per patient, with no statistical difference between the two groups (P = 0.715). Compared with the non-IGS group, the IGS group had an overall cost saving of 350.90 CNY per patient. Although the procedure-related medical costs of IGS group were increased by 1,286.12 CNY compared with the non-IGS group, this was more than offset by other costs.

CONCLUSION

The results of the study indicated that the IGS may avoid occurrence of rehospitalization and reoperation due to postoperative bleeding. Although the use of navigation technology increased the cost of surgery, its clinical effectiveness brought other medical cost savings, resulting in no significant difference in the overall cost of navigation surgery compared to conventional surgery. The IGS should be considered cost-effectiveness in the treatment of FESS.

Ambient air pollution and hospitalization for type 2 diabetes in China: A nationwide, individual-level case-crossover study

Scarce evidence is available on the short-term association between air pollution and type 2 diabetes (T2D). We aimed to evaluate the associations between short-term exposure to six criteria air pollutants and hospitalization for T2D based on a national registry. We conducted an individual-level, time-stratified case-crossover study among inpatients with a primary diagnosis of T2D from 153 hospitals across 20 provincial regions in China (2013-2021). Daily concentrations of fine particulate matter (PM_2.5), inhalable particle (PM₁₀), nitrogen dioxide (NO₂), sulfur dioxide (SO₂) and carbon monoxide (CO), and ozone were collected from the nearest monitoring stations. T2D patients were separated into those admission for T2D with and without complications. Distributed lag non-linear models combined with conditional logistic regressions were used to estimate the associations. A total of 88,904 patients were hospitalized for T2D. Short-term exposures to all six air pollutants above except for ozone were significantly associated with the risk of hospitalization for T2D and both subclasses. An interquartile range increase in the concentrations of PM_2.5, PM₁₀, NO₂, SO₂, and CO at lag 0-2 d was associated with higher hospitalization risk of T2D by 1.71% (95%CI: 0.56%, 2.87%), 2.08% (0.88%, 3.29%), 4.85% (3.29%, 6.44%), 2.44% (1.22%, 3.67%) and 2.55% (1.24%, 3.88%), respectively. The associations of T2D hospitalizations were stronger in cold season than in warm season. Air pollutants had more acute and stronger associations with T2D with complications. The exposure-response relationship curves showed no thresholds, and the slopes were larger for T2D with complications. This nationwide individual-level, case-crossover study provides the first comprehensive evidence that short-term exposure to multiple criteria air pollutants may increase the risk of hospitalizations for T2D, especially for T2D with complications.

Real-world treatment patterns and stroke risks among patients with atrial fibrillation in China

Aim: To describe patient characteristics, treatment patterns and stroke risks for patients with newly diagnosed atrial fibrillation (AF) in China. Patients & methods: Patients with AF were identified from an electronic medical record database in China (n = 22,535). Results: Less than half of patients (n = 9971; 44.2%) received antithrombotic medications following AF diagnosis; of these patients, 93.7% received anticoagulants and 71.3% received antiplatelets. Only 27.6% of patients received oral anticoagulants. Multivariate Cox proportional hazard model analysis found that patients treated with antithrombotic medications had a significantly lower risk of stroke compared with patients who were not treated (hazard ratio: 0.4; 95% CI: 0.37-0.43). Conclusion: The results suggest that antithrombotic medications, especially oral anticoagulants, are underused in China.

Comparison of Enterprise stent 2 with 1 in assisting coiling of ruptured aneurysms: a real-world study

Aim: To investigate the effectiveness and safety of the Enterprise 2 (E2) stent versus the Enterprise 1 (E1) stent in treating ruptured intracranial aneurysms (RIAs) in China. Materials & methods: The authors conducted an electronic medical record analysis for patients with RIAs who underwent E1/E2 deployment. The main outcomes were immediate complete occlusion (ICO), patient functional outcomes, complications and aneurysm recurrence. Results: Stent deployment was successful in all patients (E2: 90; E1: 270). ICO and patients with good functional outcomes at discharge were similar between E2 and E1 (80.0% vs 75.1% and 78.7% vs 81.1%, respectively). The E2 group had a significantly lower complication rate compared with the E1 group (7.8% vs 16.4%; odds ratio: 0.36; 95% CI: 0.15-0.91; p = 0.031). By 6 months post-discharge, the two groups had comparable patient functional outcomes and aneurysm recurrence (E2 vs E1: 80.2% vs 81.9% and 13.3% vs 14.9%). Conclusion: Compared with the E1 stent, the E2 stent had similar effectiveness but a lower complication risk in treating RIAs.

Cost-effectiveness analysis of continuous subcutaneous insulin infusion versus multiple daily insulin for treatment of children with type 1 diabetes

OBJECTIVE

To evaluate the health economics of using continuous subcutaneous insulin infusion (CSII) therapy versus multiple daily injections (MDI) therapy in children and adolescent patients with type 1 diabetes (T1D) in Qingdao, China.

METHODS

A long-term cost-effectiveness analysis was conducted using the IQVIA Core Diabetes Model (CDM). The baseline characteristics of the simulated cohorts were obtained from 213 pediatric T1D patients who received care with CSII(104 cases) or MDI(109 cases) in Qingdao from 1 January 2015 to 31 March 2019. In the essential case, the expenditure of the complications and treatment of the disease with both therapies were evaluated in Chinese currency from the perspective of healthcare system. In a secondary analysis, the model used a 70-year time horizon, and a discount rate of 5% was applied to all future health outcomes and costs. A one-way sensitivity analysis was conducted on delta HbA1c, different prices of insulin pump, price of each upgrade cycle rates and different discount rates. Uncertainty was also evaluated by the probability sensitivity analysis and scenario analysis.

RESULTS

In the base-case analysis, the lifetime total costs were lower for CSII group at ¥630,871 per patient compared with ¥672,672 for MDI group. The quality-adjusted life years (QALYs) gained were 11.612 and 11.197 for patients treated with CSII group and MDI group, respectively. The CSII group was cost-saving compared to MDI group. The feasibility of CSII group being cost-effective was 100% under the threshold of 3 times per capita GDP of China in 2019 (¥212,676) which was indicated from the probabilistic sensitivity analysis. Regarding scenario analysis, the ICER of the CSII group compared to MDI was between -151,583 and 153,366 RMB/QALYs, which is cost-effective.

CONCLUSIONS

This economic evaluation compared CSII therapy versus MDI therapy for T1D children and adolescent patients in China and findings indicate that CSII should be considered a preferred treatment modality to MDI.

Cost-Effectiveness of Linaclotide Compared to Osmotic Laxatives in the Treatment of Irritable Bowel Syndrome with Constipation in China

INTRODUCTION

Linaclotide, a selective agonist of guanylate cyclase C, was highly recommended for the treatment of irritable bowel syndrome with constipation (IBS-C). However, the cost-effectiveness of linaclotide in Chinese is not known, and this study aimed to assess the cost-effectiveness of linaclotide for patients with IBS-C.

METHODS

An economic evaluation was conducted with a Markov model from a societal perspective. The Markov model was structured to simulate the discontinuation and continuation of medication in IBS-C patients in clinical practice, as well as the revisit and non-visit of non-responding patients. The cycle of the model was 4 weeks, and the time horizon was 1 year. The efficacy data in the model was from the risk ratios obtained by the meta-analysis and the calculation of the response rate of the three medications. The utility, discontinuation rate of the medication, and revisit rate data were from published literature, while the cost data were obtained from experts' opinions and published literature. A series of sensitivity analyses was performed on parameters potentially having impact on the model outputs.

RESULTS

The QALYs (quality-adjusted life years) gained for 1-year treatment with linaclotide, polyethylene glycol, and lactulose were 0.821, 0.795, and 0.781, respectively. The corresponding total costs were CNY 7,721 (USD 1,120), CNY 8,797 (USD 1,276) and CNY 9,481 (USD 1,375). In both comparisons, linaclotide was dominant. Compared with polyethylene glycol and lactulose, the likelihood of linaclotide being cost-effective was 100% for both, using 1 times per capita GDP per QALY as willingness-to-pay threshold.

CONCLUSIONS

IBS-C seriously affects the quality of life of patients with IBS-C, and linaclotide can improve symptoms and quality of life at less cost.

Ultrasonic surgical and electrosurgical system (USES) with conventional ultrasonic scalpel (CUS) in gastrectomy: a retrospective cohort study

Background

Harmonic ACE +7 Shears with Advanced Hemostasis is an upgraded ultrasonic device, an ultrasonic surgical and electrosurgical system (USES). The study aimed to evaluate the economic and clinical effectiveness of the USES compared with the conventional ultrasonic scalpel (CUS) in gastrectomy.

Methods

We conducted a single-center, retrospective cohort study using the electronic medical records in China. We collected intraoperative and postoperative data from gastric cancer patients who underwent the endoscope-assisted distal gastrectomy from 2018 to June 30, 2019. Procedure-related costs were estimated. We used linear regression by controlling a set of covariates to assess the effect of USES on outcomes.

Result

Out of 87 eligible patients, the USES group (40 patients) and CUS group (47 patients) were comparable in terms of age, medical history and stages of cancer. Compared with the CUS, the USES saved 4.27 hemoclips per person (95% CI 0.57–7.97, p < 0.05) and 34.18 ml intraoperative blood per person (95% CI 8.74–59.62 ml, p < 0.05), respectively. Postoperative length of stay (LOS) was shorter in the USES group (7.90 ± 1.95 vs. 9.26 ± 2.81 days) but the difference was not statistically significant (p = 0.05).

Conclusions

The USES group was associated with fewer hemoclips use and intraoperative blood loss in patients undergoing laparoscopic gastrectomy at comparable costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00344-5.

Treatment and economic burden of mucormycosis in China: Case report review and burden estimation

What is known and Objective

Mucormycosis is an opportunistic fungal infection associated with low incidence but high mortality. Few studies have shown the treatment and disease burden of mucormycosis in China. This study aims at collecting all the reported cases to describe the characteristics and treatment patterns and to assess the economic burden of mucormycosis in China.

Methods

We conducted a literature review of mucormycosis case reports in Chinese patients to summarize the characteristics and treatment patterns of the disease in China. An economic model was built to evaluate the total cost of mucormycosis per person, including direct medical cost, direct non‐medical cost and indirect cost.

Results and Discussion

A total of 676 case reports showed that the most common type of mucormycosis was pulmonary mucormycosis (299/676, 44.2%), and rhinocerebral mucormycosis had the highest case fatality rate (122/185, 68.5%). Among those who used empiric therapies, 48.8% (231/473) did not include anti‐mucor drugs; 79.8% (336/421) of the therapies include amphotericin B (AMB) or AMB‐lipo after detection of mucormycetes; 98.6% (69/70) of the reported adverse events were associated with AMB and AMB‐lipo. The duration of treatment ranged from 90 to 180 days; the length of stay ranged from 22 to 95 days. The average total cost per patient was 166 thousand Chinese Yuan (CNY), of which 93.1% was the direct medical cost (155 thousand CNY).

What is new and Conclusion

There are a limited number of antifungal treatment options for mucormycosis in China. This study highlights the critical need to introduce innovative and broader spectrum antifungal drugs with improved safety, better clinical efficacy, easier administration and reduced economic burden to Chinese mucormycosis patients.

Newly diagnosed asthma in China: initial severity and changes over a 1-year management period

Background

There are no large sample, epidemiological data describing initial asthma severity and change. We used a large health care database to examine asthma severity at initial diagnosis, and the changes in severity over the first year of management.

Methods

The clinical data of patients diagnosed with asthma for the first time were collated from the SuValue electronic medical database. The following inclusion criteria were applied: (I) patients who were 14 years or older at the time of first diagnosis; (II) initial diagnosis occurred between Jan 2001 and Mar 2019; (III) patients were followed up for at least 12 months; (IV) patients had follow-up visits every 3 months. Disease severity at diagnosis and at each follow-up visit, medications prescribed were collated and analyzed.

Results

A total of 7,654 adult patients with newly diagnosed asthma from tertiary hospitals (26.38%) and secondary hospitals (73.62%), who were followed up for at least 12 months, were included in this retrospective analysis. Approximately 54% of patients were females and the largest age group was over 60 years old (37.66%). Nearly 16% of patients were moderate to severe asthma initially. The proportions of patients with moderate and severe asthma decreased during the first 6 months, and remained stable thereafter. At the end of the 1-year follow-up period, 2.7% of patients had severe asthma. Patients with mild asthma tended to continue to have mild asthma in the following 3 months (>76.19%). However, of the patients with mild or moderate asthma at 3 months, 92.85% and 75.1%, respectively, experienced maintenance and reduction in severity and had mild asthma by 12 months. 1.26% and 3.15% of patients with mild or moderate asthma, respectively, progressed to severe asthma by 12 months.

Conclusions

Patients with mild asthma did not progress but rather, remained stable with mild asthma over the year. A proportion of patients diagnosed with moderate and severe asthma remained stable over a 1-year period. Further studies should be conducted to examine the clinical features of newly diagnosed patients with severe asthma without reduction in severity in order to facilitate intensive treatment and reduce the disease burden for these patients.

Data in Brief of: Clinical benefits of moxifloxacin as initial treatment of community-acquired pneumonia: Data from meta-analyses

Moxifloxacin and levofloxacin are currently recommended as empirical initial treatment options for community-acquired pneumonia (CAP) in China by clinical guidelines and widely used in clinical settings. Several clinical outcomes comparing the efficacy and safety profiles of moxifloxacin versus levofloxacin through a meta-analysis were reported in paper 'Clinical benefits and cost-effectiveness of moxifloxacin as initial treatment for community-acquired pneumonia: a meta-analysis and economic evaluation'. In this dataset, we aimed at investigating more clinical endpoints comparing the efficacy and safety of moxifloxacin and levofloxacin in the treatment of CAP.

Network Meta-analysis of the Therapeutic Effects of Hypoglycemic Drugs and Intensive Lifestyle Modification on Impaired Glucose Tolerance

PURPOSE

In the Guidelines for the Prevention and Control of Type 2 Diabetes in China (2017 edition), intensive lifestyle interventions are recommended for preventing the progression of impaired glucose tolerance (IGT) to type 2 diabetes mellitus. Acarbose and metformin can also be considered if intensive lifestyle modification has been ineffective for 6 months. But the effects of intensive lifestyle modification and glucose-lowering drug interventions that work best in the population with IGT are unclear. This network meta-analysis assessed the effectiveness of intensive lifestyle modification, acarbose, and metformin in treating populations with IGT.

METHODS

We systematically searched both Chinese- and English-language databases, including China Knowledge, the Cochrane Library, Embase, PubMed, VIP, and Wanfang, for articles published between database inception and September 2019. Randomized, controlled clinical trials in patients with IGT treated with acarbose, metformin, and intensive lifestyle modification were assessed for eligibility. The data from all included studies were evaluated by 2 reviewers independently in accordance with the Cochrane Handbook for Systematic Reviews of Intervention version 6.0. A network meta-analysis was performed by using R software version 3.6.1.

FINDINGS

The data from 53 randomized controlled trials were included in the review, with a sample size of 21,208 patients. Compared with the control group, the use of acarbose, metformin, and/or intensive lifestyle modification was associated with reduced rates of progression to diabetes (relative risks [RRs] [95% credible intervals]: acarbose, 0.37 [0.29-0.47]; metformin, 0.39 [0.30-0.50]; intensive lifestyle modification, 0.61 [0.50-0.73]). The surface under the cumulative ranking (SUCRA) value of acarbose was 88.35%, supporting that acarbose was more effective in reducing the rate of progression to diabetes compared with controls. With acarbose, metformin, and intensive lifestyle modification, the rates of achieving a normal glucose level were increased by RR = 2.1, 1.7, and 1.2, respectively when compared with control group. The SUCRA value of acarbose was 99.69%, supporting the optimal effect of acarbose in achieving a normal blood glucose level.

IMPLICATIONS

In this meta-analysis in patients with IGT, compared with controls, acarbose and metformin were associated with decreased rates of progression to diabetes and increased rates of achieving a normal glucose level. Acarbose use was associated with an increased rate of achieving a normal glucose level, while intensive lifestyle modification was not.

Cost-effectiveness Analysis of Dienogest Compared With Gonadotropin-Releasing Hormone Agonist After Conservative Surgery for Endometriosis in China

PURPOSE

Although the clinical effect of dienogest for endometriosis after conservative surgery has been proven, the cost-effectiveness of this new pharmacotherapy remains to be determined. We aimed to assess the health economic implications of dienogest versus a gonadotropin-releasing hormone agonist (GnRH-a; goserelin in the Chinese setting.

METHODS

A decision tree model was developed to evaluate the cost-effectiveness of dienogest compared with a GnRH-a (goserelin) after conservative surgery for endometriosis during a 2-year time horizon from the perspective of a health care system in China. The cost of drugs, use of outpatient care facilities, administration of medications, routine laboratory work and imaging studies, and treatment of drug-related adverse events were considered. We obtained clinical efficacy data from the peer-reviewed literature. Base case findings were further tested with 1-way and probabilistic sensitivity analyses.

FINDINGS

The model projects that treatment with dienogest would result in a modest incremental 0.02 quality-adjusted life-year gains compared with a GnRH-a (goserelin) (1.48 vs 1.46) at a cost saving of ¥7274 (¥22,809 vs ¥30,164). Probabilistic sensitivity analysis found that dienogest has a 100% probability of % being considered cost-effective compared with a GnRH-a (goserelin) at the willingness-to-pay threshold of 3 times the gross domestic product per capita (¥64,644 × 3) of China in 2018 (¥1 = US$0.1454 and €0.1248).

IMPLICATIONS

Dienogest is more effective and cost-saving compared with a GnRH-a (goserelin) in the treatment of patients with endometriosis after conservative surgery in China.

Clinical Benefits and Cost-Effectiveness of Moxifloxacin as Initial Treatment for Community-Acquired Pneumonia: A Meta-Analysis and Economic Evaluation

PURPOSE

Moxifloxacin and levofloxacin are currently recommended as empirical initial treatment options for community-acquired pneumonia (CAP) in China according to guidelines. Most studies that evaluated the efficacy and safety of moxifloxacin and levofloxacin in treating CAP as initial empirical treatment were single-centered trials assessing different clinical end points. In addition, there is limited research investigating moxifloxacin's clinical benefits in the context of health care resource utilization and reimbursement from the payer's perspective in China. Hence, this study was aimed at comparing the clinical efficacy of moxifloxacin and levofloxacin by conducting a meta-analysis and assessing their economic value from the China payer's perspective through a cost-utility analysis model.

METHODS

For the meta-analysis, 6 bibliographic databases were searched for relevant publications from January 2000 to August 2020, and studies were assessed for eligibility under predetermined criteria. Meta-analysis was performed by using a random effects model when analyses included >2 trials. For the economic evaluation, a decision-tree model was constructed to investigate the cost-utility of moxifloxacin versus levofloxacin as initial regimens in the treatment of CAP inpatients. Parameter values were derived from meta-analysis, published literature, and clinician survey. The outcome was reported in the form of an incremental cost-effectiveness ratio. One-way sensitivity analysis and probabilistic sensitivity analysis were undertaken to assess the robustness of the model.

FINDINGS

Twenty-seven randomized controlled trials were included in the meta-analysis. Results indicated that the clinical response rate at the test-of-cure visit with initial treatment of moxifloxacin was significantly higher than that of levofloxacin (3441 patients; random effects model; I² = 49%; odds ratio, 3.35; 95% CI, 2.35-4.77; P < 0.001). In terms of the safety profile, total adverse events were not significantly different between the 2 groups (2770 patients; random effects model; I² = 40%; odds ratio, 0.77; 95% CI, 0.56-1.06; P = 0.11). Output of the cost-utility model showed that under the willingness-to-pay threshold of one-time China gross domestic product per capita, moxifloxacin is dominant over levofloxacin, being less costly and more efficacious (0.002 quality-adjusted life year gained, CNY 844 [US$131] saved in total cost, negative incremental cost-effectiveness ratio). Sensitivity analyses indicated the robustness of the model as moxifloxacin remained dominant when model parameter values fluctuated.

IMPLICATIONS

Moxifloxacin is more efficacious than levofloxacin as the initial empirical treatment for CAP. In addition, treatment of CAP with moxifloxacin instead of levofloxacin is expected to be cost-saving from the perspective of payers in China. However, for the cost-utility analysis, in the absence of a national representative database on costs for hospitalization in China, inputs in the cost-utility model could be underestimated or overestimated due to estimating errors applied to both treatment arms. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

Using machine learning to predict post-operative depth of focus after cataract surgery with implantation of Tecnis Symfony

OBJECTIVE

To predict post-operative depth of focus (DoF) using machine learning techniques after cataract surgery with Tecnis Symfony implantation and determine associated impact factors.

METHODS

This was a retrospective cohort study among patients receiving Tecnis Symfony implantation, an extended-range-of-vision intraocular lens, during October 2016-January 2020 at Daqing Oilfield General Hospital, China. Four different predictive models were used to predict good post-operative DoF (⩾2.5 D): Extreme Gradient Boost (XGBoost), random forest (RF), LASSO penalized regression, and multivariable logistic regression (MLR). Apriori algorithm was employed to further explore the association between patient attributes and DoF.

RESULTS

A total of 182 unique cases (143 patients) were included. The XGBoost model produced the best predictive accuracy compared to RF, LASSO, and MLR models. Overall performance of the best fitting XGBoost model was as follows: accuracy = 70.3%, AUC = 80.2%, sensitivity = 65.5%, and specificity = 87.5%. The Apriori algorithm identified six preoparative attributes with substantial effects on good post-operative DoF: low anterior chamber depth (ACD) (1.9 to <2.5 mm), smaller pupil size (1.7 to <2.5 mm), low-to-mid axial length (21 to <23 mm), minimum astigmatism degree (-0.2 to 0 diopter), low IOP (9 to <12 mmHg), and medium lens target refractive error (-0.5 to <-0.25 diopter).

CONCLUSIONS

Machine Learning models were able to predict good post-operative DoF among cataract patients receiving a Tecnis Symfony ocular lens implantation. The accuracy of the model was above 70%. The Apriori algorithm identified six preoperative attributes with a strong association with post-operative DoF.

Economic analysis of sugammadex versus neostigmine for reversal of neuromuscular blockade for laparoscopic surgery in China

BACKGROUND

Neuromuscular blockade and pneumoperitoneum (PP) are important factors to ensure successful laparoscopic surgery. However, residual neuromuscular blockade (rNMB) and PP are associated with many unfavorable complications. The aim of this study is to compare the cost-effectiveness of using sugammadex versus neostigmine in laparoscopic surgery in China.

METHODS

A decision tree model was developed with a time horizon based on laparoscopic surgery related hospitalization duration. 2000 patients using sugammadex or neostigmine were simulated within the model. The model outcomes included incidence of rNMB and PP related complications and their treatment costs. Data on clinical efficacy, safety and cost were collected from published literature and interviews of physicians.

RESULTS

The model projected that treatment with sugammadex instead of neostigmine would lead to 673 fewer total complications, including rNMB/PP related complications, hospitalization, and other AEs (621 events versus 1294 events, respectively). Use of sugammadex was associated with an incremental medication cost of ¥1,360,410. However, 93.6% of the increased medication cost can be off-set by the reduced costs attributable to treatment of rNMB related complications, PP related complications, hospitalization and other adverse events in sugammadex group. In aggregate, the sugammadex group incurred an incremental cost of ¥86,610 to prevent 673 complications, (¥128.56 per one rNMB/PP related complications prevention). One-way sensitivity analysis confirmed the robustness of the model.

CONCLUSIONS

Use of sugammadex in replacement of neostigmine would result in significantly lower rNMB/PP related complications but at a substantially higher medication cost. Upon accounting for the costs associated with treatment of rNMB/PP related complications, 93.6% of medication cost is projected to be offset. In balance, sugammadex appears to offer good value for reversal of neuromuscular blockade for laparoscopic surgery in China.

Cost-effectiveness of aripiprazole orally disintegrating tablets in the treatment of schizophrenia in China

BACKGROUND

Orally disintegrating tablet (ODT) formulation of antipsychotics is one of the innovative drug delivery systems developed to improve medication adherence. We aimed to evaluate the cost-effectiveness of aripiprazole ODT vs. aripiprazole standard oral tablet (SOT), as well as olanzapine SOT in China.

METHODS

We developed a discrete event simulation model from government payers' perspective. On the entry, 100,000 patients in each group were simulated for relapse, adverse events, changing adherence level, medication discontinuation, switching or quitting in response to three different medication adherence levels. The model projected quality adjusted life years (QALYs) and treatment costs over a 1-year time horizon. Parameter uncertainties were assessed through sensitivity analyses.

RESULTS

The QALYs per patient over 1-year treatment with aripiprazole ODT, aripiprazole SOT, or olanzapine SOT, were 0.7282, 0.7112, and 0.7218, respectively. The corresponding costs were $1,423, $2,215, and $1,493. In both comparisons, aripiprazole ODT was dominant. Compared with aripiprazole SOT and olanzapine SOT, the likelihood of aripiprazole ODT being cost-effective was 99.2% and 69.2%, respectively, using 3 times per capita GDP per QALY as willingness-to-pay threshold.

CONCLUSIONS

The aripiprazole ODT is associated with more QALYs at lower costs compared with both aripiprazole SOT and olanzapine SOT in treating schizophrenia in China.

Economic burden of needlestick injuries among healthcare workers in China

Objective: To estimate the economic burden of needlestick injuries (NSIs) among healthcare workers (HCWs) in China.Design: A model was built to evaluate the economic burden of NSIs.Methods: The cost model was developed from a societal perspective, including both direct and indirect costs, with lifetime horizon. The direct costs were categorized into infection prevention and treatment of infections. The indirect cost included productivity loss of both HCWs and his/her family members due to the blood-borne infections. Sub-group analyses were conducted to estimate the cost per NSI when the source patient (SP) was confirmed with hepatitis B virus/hepatitis C virus/human immunodeficiency virus (HBV/HCV/HIV) infection. One-way and probabilistic sensitivity analyses were conducted for all parameters to examine the robustness of the result.Results: The model projected a total cost of ¥699 for each NSI (direct and indirect cost were ¥553 and ¥146, respectively). The cost per NSI when the SP was confirmed with HBV/HCV/HIV was ¥4,238, ¥18,404, and ¥6,152, respectively. The total economic burden of NSIs among HCWs in China was estimated to be ¥5.8 billion, and about half of the cost was associated with NSIs in nurses, at ¥2.8 billion.Limitations: This study did not incorporate the costs of litigation/psychological, and the prevalence of the infections was based on the general population, so the actual costs per NSI may be underestimated. More real-world studies of treatment cost about HBV/HCV are needed to further supporting this study.Conclusions: The economic burden of NSIs among HCWs in China is substantial. Comprehensive NSI prevention programs, including implementation of safety needles and devices, have high potential for healthcare institutions to achieve downstream cost savings and cost offsets.

Cost-effective analysis of clopidogrel versus aspirin for high risk patients with established peripheral arterial disease in China

Objective: To assess the cost-effectiveness of clopidogrel versus aspirin for high risk patients (pre-existing symptomatic atherosclerosis or multi-vascular territory involvement) with established peripheral arterial disease (PAD) for secondary prevention of atherothrombotic events in a Chinese setting.Methods: A Markov model with a lifetime horizon was developed from the perspective of the national healthcare system in China. The primary outputs are quality adjusted life years (QALYs), direct medical costs, and the incremental cost-effectiveness ratios (ICERs). Clinical efficacy data were obtained from the CAPRIE trial. Drug acquisition cost, other direct medical costs, and utilities were from pricing records and the literature. One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were conducted to test the robustness of the model on all parameters.Results: In patients with pre-existing atherosclerosis, 2 years of treatment with clopidogrel and aspirin would yield total QALYs of 8.776 and 8.576 at associated costs of ¥18,777 ($2,838) and ¥12,302 ($1,859), respectively, resulting in an ICER of ¥32,382 ($4,893) per QALY gained. In patients with PVD, secondary prevention with the same drugs would expect to lead to total QALYs of 8.836 and 8.632 at associated costs of ¥18,518 ($2,798) and ¥12,041 ($1,820), respectively, resulting in a corresponding ICER of ¥31,743 ($4,797) per QALY gained. The results were most sensitive to the discount rate for future outcomes and costs. The PSA indicated that the probability of clopidogrel being cost-effective was 100% at the willingness-to-pay threshold of 3-times GDP.Conclusions: Secondary prevention with clopidogrel is an attractive cost-effective option compared with aspirin for high risk patients with established PAD from the perspective of the national healthcare system in Chinese settings.

Association Between Adherence to Maintenance Medication in Patients with COPD and Acute Exacerbation Occurrence and Cost in China: A Retrospective Cohort Database Study

Background

This study aimed to evaluate the association between adherence to maintenance medication (ie, inhaled bronchodilators, inhaled corticosteroid/long-acting beta-2 agonist [ICS/LABA] combinations, and oral therapy) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and related costs among patients with chronic obstructive pulmonary disease (COPD) in China.

Patients and Methods

Claims data from the hospitals of a metropolitan city in south China between January 2014 and December 2016 were obtained. Patients with COPD with ≥2 maintenance medication claims during 1 year were included. Adherence was measured by the proportion of days covered (PDC). The interaction of medication class×adherence was considered when building models.

Results

A total of 11,708 patients met the inclusion criteria, of whom 10.8% were highly adherent (PDC≥0.8). There were significant interaction effects of drug category on hospitalized AECOPD risk (P≤0.001), hospitalized AECOPD rate (P<0.001), and 1-year hospitalized AECOPD treatment costs (P=0.012). There was a relationship between high adherence and outcomes for ICS/LABA combinations (n=3,419), ie, relative risk of hospitalized AECOPD was reduced by 34.8% (adjusted odds ratio=0.65; 95% confidence interval (CI): 0.54–0.79; P<0.001) while the frequency of hospitalized AECOPD per patient-year was reduced by 24.4% (adjusted rate ratio=0.76; 95% CI: 0.65 to 0.87; P<0.001). Mean 1-year per-patient hospitalized AECOPD costs were reduced by 37.8% (mean difference=−848 USD; 95% CI: −1435–262 USD; P<0.001). Patients taking oral mucolytics and having high adherence had worse AECOPD outcomes than patients with poor adherence.

Conclusion

High adherence to ICS/LABA maintenance therapy was associated with reduced hospitalized AECOPD rates and costs in Chinese patients with COPD.

Random forest for prediction of contrast-induced nephropathy following coronary angiography

The majority of prediction models for contrast-induced nephropathy (CIN) have moderate performance. Therefore, we aimed to develop a better pre-procedural prediction tool for CIN following contemporary percutaneous coronary intervention (PCI) or coronary angiography (CAG). A total of 3469 patients undergoing PCI/CAG between January 2010 and December 2013 were randomly divided into a training (n = 2428, 70%) and validation data-sets (n = 1041, 30%). Random forest full models were developed using 40 pre-procedural variables, of which 13 variables were selected for a reduced CIN model. CIN developed in 78 (3.21%) and 37 of patients (3.54%) in the training and validation datasets, respectively. In the validation dataset, the full and reduced models demonstrated improved discrimination over classic Mehran, ACEF CIN risk scores (AUC 0.842 and 0.825 over 0.762 and 0.701, respectively, all P < 0.05) and common estimated glomerular filtration rate. Compared to that for the Mehran risk score model, the full and reduced models had significantly improved fit based on the net reclassification improvement (all P < 0.001) and integrated discrimination improvement (P = 0.001, 0.028, respectively). Using the above models, 2462 (66.7%), 661, and 346 patients were categorized into low (< 1%), moderate (1% to 7%), and high (> 7%) risk groups, respectively. Our pre-procedural CIN risk prediction algorithm (http://cincalc.com) demonstrated good discriminative ability and was well calibrated when validated. Two-thirds of the patients were at low CIN risk, probably needing less peri-procedural preventive strategy; however, the discriminative ability of CIN risk requires further external validation. TRIAL REGISTRATION: ClinicalTrials.gov NCT01400295.

Economic evaluation of olmesartan/amlodipine fixed-dose combination for hypertension treatment in China

Objectives: To evaluate the cost-effectiveness of olmesartan/amlodipine fixed-dose combination vs olmesartan and amlodipine free combination, amlodipine single drug, and valsartan/amlodipine fixed-dose combination in the treatment of hypertensive patients from payer perspective in China.Methods: A Markov model was constructed, which included five health states of hypertensive patients who are aged 35-84 years at baseline and free of cardiovascular disease. Clinical data were obtained from a network meta-analysis. Epidemiology data, adverse events (AEs), cost, and utility data were obtained from the literature. The cost associated with AEs was estimated based on the cost of same symptoms of hypertensive patients in an electric medical record database. The model projected quality-adjusted life years (QALYs) gained, total costs per patient in a 20-year time horizon, and incremental cost-effectiveness ratios. Probability sensitivity analyses (PSA) and one-way sensitivity analyses were conducted for the main parameters to test the robustness of the model.Results: Compared to olmesartan and amlodipine free combination, amlodipine, and valsartan/amlodipine fixed-dose combination, treatment with olmesartan/amlodipine fixed-dose combination led to fewer CVD events and deaths; resulted in an incremental cost of ¥-5,439 ($-791.36), ¥6,530 ($950.09), and ¥-1,019 ($-148.26) and gained additional QALYs of 0.052, 0.094, and 0.037 per patient, respectively. Compared with olmesartan and amlodipine free combination and valsartan/amlodipine fixed-dose combination, olmesartan/amlodipine fixed-dose combination was dominant. Compared with amlodipine alone, the incremental cost-effectiveness ratios were below the WHO recommended cost-effectiveness threshold, indicating the olmesartan/amlodipine fixed-dose combination was a cost-effective option for hypertensive patients in China. The 10-years' time horizon scenario analysis showed similar results to the 20-years' time horizon. Probabilistic sensitivity analysis and one-way sensitivity analyses showed the robustness of the model results.Conclusions: Olmesartan/amlodipine fixed-dose combination confers better health outcomes and costs less compared with olmesartan and amlodipine free combination and valsartan/amlodipine fixed-dose combination, and is cost-effective compared to amlodipine for hypertension treatment in China.

A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation

INTRODUCTION

Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China.

OBJECTIVE

We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers.

METHODS

The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20 years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained.

RESULTS

RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20 years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS₂ score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF).

CONCLUSION

Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.

Meta-Analysis and Cost-Effectiveness Analysis of Insulin Glargine 100 U/mL Versus Insulin Degludec for the Treatment of Type 2 Diabetes in China

INTRODUCTION

To evaluate the efficacy and safety as well as the long-term cost-effectiveness of insulin glargine 100 U/mL (IGlar) versus insulin degludec (IDeg) for the treatment of type 2 diabetes mellitus (T2DM) from the Chinese healthcare system perspective.

METHODS

A systematic search of English and Chinese electronic databases for randomized controlled trials (RCTs) comparing IGlar with IDeg for the treatment of T2DM was performed, followed by a meta-analysis to compare the efficacy and safety of IGlar versus IDeg. The CORE Diabetes Model was used to estimate lifetime costs, quality-adjusted life years (QALYs) gained, and cost-effectiveness of IGlar versus IDeg. One-way and probabilistic sensitivity analyses were conducted to assess the underlying parameter uncertainty.

RESULTS

Six RCTs were included in the meta-analysis. The IGlar group showed a statistically significant decrease in glycated hemoglobin (HbA_1c) from baseline compared to the IDeg group (mean difference [MD] 0.08%, 95% confidence interval [CI] 0.01-0.14%, P = 0.02). Body mass index (BMI) control was numerically better in the IGlar group than in the IDeg group (MD 0.07 kg/m², 95% CI - 0.01 to 0.14 kg/m², P  = 0.08). In terms of hypoglycemia, the incidence of non-severe overall hypoglycemia was comparable between the IDeg and IGlar patient groups (P  > 0.05), while the incidence of non-severe nocturnal hypoglycemia (relative risk [RR 0.79], 95% CI 0.70-0.90, P < 0.01) and the event rates of non-severe overall (RR 0.91, 95% CI 0.85-0.97, P < 0.01) and non-severe nocturnal hypoglycemia (RR 0.91, 95% CI 0.85-0.97, P < 0.01) were lower in the IDeg group. The incidences and event rates of both severe overall and nocturnal hypoglycemia were similar for the two groups (P  > 0.05). The cost-effectiveness analysis showed that IGlar is the dominant treatment option compared with IDeg, with a lifetime savings of 1004 Chinese yuan in direct medical costs and a net gain of 0.015 QALYs per patient. Both one-way and probabilistic sensitivity analyses confirmed the robustness of the results.

CONCLUSIONS

IGlar is a cost-saving option with incremental effectiveness compared with IDeg for the treatment of T2DM in China.

FUNDING

Sanofi China.

Treatment Patterns in Patients With Newly Diagnosed Type 2 Diabetes in China: A Retrospective, Longitudinal Database Study

PURPOSE

The objectives of this study were to examine the patterns of antihyperglycemic drug (AHD) therapy among patients with newly diagnosed type 2 diabetes mellitus (T2DM) in the general Chinese population, stratified by initial hemoglobin (Hb) A_1c level, and to assess whether treatment patterns are consistent with the recommendations published in the China Diabetes Society's clinical treatment guideline.

METHODS

A retrospective database analysis was conducted, and data were obtained from the SuValue database. Prescribing patterns for diabetes treatments were determined from data obtained from the Nanhai District-based electronic medical records database, a subset of the SuValue database. Data from patients newly diagnosed with T2DM who also had at least 2 prescriptions for AHD medications after diagnosis and at least 1 HbA_1c test result during the 12 months prior to AHD treatment initiation, between January 1, 2004, and July 22, 2018, were included in the analysis. ANOVA, χ² test, and Kaplan-Meier survival analysis were used to examine differences between 4 initial-HbA_1c groups (<7%, 7%-<8%, 8%-<9%, and ≥9%).

FINDINGS

A total of 4712 patients were included, with women accounting for 47.8%; the mean age (SD) of the study population was 56.44 (12.57) years. Men were more likely to have had a higher HbA_1c level at initial AHD treatment (P < 0.0001). The first-line therapies most frequently prescribed were metformin combination (29.5%), followed by insulin-including treatment (25.9%), and metformin monotherapy (19.2%). Metformin monotherapy (29.5%) was most commonly prescribed in patients with an HbA_1c level of <7%; metformin combination (31.7%), in patients with an HbA_1c level of 7%-<8%; and insulin-containing treatment, in patients with HbA_1c levels of 8%-<9% (28.1%) and ≥9% (38.4%). Insulin-including treatment was more commonly prescribed than was metformin combination in patients with an initial HbA_1c level of ≥8% after initial treatment. In third- and fourth-line treatments, patients with an HbA_1c level of ≥8% more prevalently were prescribed metformin combination and insulin-including treatment, while metformin combination and "other" treatment were more generally prescribed in patients with an HbA_1c level of ≤8%. However, 8.8% of patients with an HbA_1c level of <7% were prescribed insulin-including treatment as first-line therapy. In all lines of treatment, the percentages of patients prescribed insulin were increased with initial HbA_1c levels. A similar pattern was seen with dipeptidyl peptidase 4 inhibitors after first-line treatment. Overall, the median time to treatment switch was shorter than 3 months.

IMPLICATIONS

The findings from the present study depict a comprehensive overview of AHD-treatment patterns in patients stratified by HbA_1c level. The current treatment practices observed were inconsistent the published guideline, in terms of recommendations on metformin monotherapy and insulin use in first-line therapy.

Cost-effectiveness of olanzapine in the first-line treatment of schizophrenia in China

OBJECTIVES

This study aimed to analyze (1) the cost-effectiveness of olanzapine orally disintegrating tablet (ODT) compared to olanzapine standard oral tablet (SOT) and (2) the cost-effectiveness of olanzapine-SOT compared to aripiprazole-SOT for patients with schizophrenia in China.

METHODS

A microsimulation model was adapted from a healthcare payers' perspective. The model ran over a 1-year time horizon, using quarterly cycles. The costs of adverse events were acquired through a clinical expert panel. The average bidding prices in China of olanzapine-ODT, olanzapine-SOT, aripiprazole-SOT, and other switch alternatives were used. Inpatient and outpatient medical costs were sourced from the Urban Employee Basic Medical Insurance database in Tianjin. Additionally, adherence, efficacy, safety, and utility data were taken from the literature. Uncertainty of parameters were assessed through one-way and probabilistic sensitivity analyses.

RESULTS

The total annual costs per patient in aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm are USD 2,296.05, USD 1,940.05, and USD 2,292.81, respectively. The average number of relapses per patient in 1 year in the aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm, are 0.734, 0.325, and 0.198, respectively. The quality-adjusted life years (QALYs) gained per patient in 1 year in the aripiprazole-SOT arm, olanzapine-SOT arm, and olanzapine-ODT arm are 0.714, 0.737, and 0.758, respectively. Consequently, (1) the incremental cost-effectiveness ratios (ICERs) of administrating olanzapine-ODT over olanzapine-SOT are USD 2,791.96 per relapse avoided and USD 16,798.39 per QALY gained; and (2) the ICERs of using olanzapine-SOT over aripiprazole-SOT are USD -870.39 per relapse avoided and USD -15,477.93 per QALY gained. All ICERs are under the willingness-to-pay threshold in China of USD 25,772.67. The sensitivity analyses confirmed the robustness of the results.

CONCLUSION

As the first-line treatment for schizophrenia in China, olanzapine-ODT is cost-effective compared to olanzapine-SOT and olanzapine-SOT is cost-effective compared to aripiprazole-SOT.

Abstract P5-04-17: Local network topology differences between early and late recurrence in ER+ breast cancers

Background: Late recurrence is characteristic of ER+ breast cancers. Despite an apparently effective adjuvant endocrine therapy, many breast cancers recur years after their initial endocrine treatment. Why some tumors recur early (&lt;3 years) and some recur later (&gt;5 years) is poorly understood. If systemic endocrine therapies killed all cells, recurrence would reflect only the appearance of new disease. Thus, we hypothesized that cells that survive and lie dormant may be driven, in part, by altered wiring of their cell death signaling. We, therefore, studied how cell death signaling is differentially wired in primary tumors that will recur early versus those that will recur later.

Method: Genes involved in apoptosis, autophagy, ferroptosis, necrosis, and pyroptosis were identified from KEGG to initiate network feature analysis of gene expression data from public and our first in-house gene expression dataset. Data were collected from ER+ breast cancer pre-endocrine treatment samples with up to 20 years follow-up. Publicly available datasets used were GSE6532, GSE2034, GSE7390, GSE17705, GSE12093, and TCGA. We applied our Knowledge-fused Differential Dependency Network (KDDN) analysis tool to the public datasets; KDDN has provided powerful new insights into signaling in breast and other cancers. Common gene-gene interactions (edges) predicted in at least two different datasets were extracted from all KDDN analyses results. To strengthen the relevance of these features, predicted network edges that represent known protein-protein interactions (PPI) were identified from the STRING database, and these edges were noted in the signaling graphs. Final network graphs were constructed using the common edges from all overlaid networks. We conducted IPA analysis on all nodes in the final network and selected those incorporating network hubs. We took a similar approach to our second in-house dataset, which we used for independent testing. Here, patients were included if their tumor exhibited an initial reduction in volume of at least 40% by four months in response to neo-adjuvant Letrozole. Patients were then classified into two groups during follow-up of up to 3.7 years: i) initial tumor size reduction followed by continued response (expected to recur late); ii) initial reduction followed by tumor regrowth (expected to recur early). KDDN analysis was performed on pretreatment samples from these two groups and a network created annotated with PPI information.

Results: MAPK8 and CYCS (Molecular Mechanisms of Cancer, p=1.58E-52), TNFRSF1A Neuroinflammation Signaling Pathway, p=1.26E-54), RELA, and NFKB1 (Colorectal Cancer Metastasis Signaling, p=7.94E-35), were identified as hubs. Hubs may be critical signaling components driving the differences between tumors that will become dormant and recur late. Connections between SLC25A6 and SQSTM1 (p = 0.008), BIRC2 and GABARAP (p = 0.021) in the early group, and AKT3 and IRS2 (p = 0.014) in the late group, were shared between the two final networks. With longer follow-up time on the second in-house dataset, we will better define the two groups and identify additional common phenotype specific gene-gene interactions.

Citation Format: Clarke R, Dixon M, Jin L, Pearce D, Turnbull A, Selli C, Hu R, Zwart A, Wang Y, Xuan J, Sengupta S, Sims A, Liu MC. Local network topology differences between early and late recurrence in ER+ breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-17.

Clopidogrel Versus Aspirin for the Treatment of Acute Coronary Syndrome After a 12-Month Dual Antiplatelet Therapy: A Cost-effectiveness Analysis From China Payer's Perspective

PURPOSE

Monotherapy with either aspirin or clopidogrel is recommended for long-term use after discontinuation of dual-antiplatelet therapy (DAPT) for acute coronary syndrome (ACS) management after percutaneous coronary intervention (PCI). The present study is to evaluate the cost-effectiveness of clopidogrel versus aspirin after 12-month DAPT for patients with ACS who underwent PCI in China.

METHODS

A 2-part model was developed to estimate the cost-effectiveness of clopidogrel compared with aspirin. The short-term part was a decision tree that included health states such as myocardial infarction (MI), stroke, MI and stroke, cardiovascular death, and death from other causes with a treatment horizon of 1 year (base case), 2 years or 3 years after 12-month DAPT. Major bleeding was included. The long-term (lifetime) part was a Markov model that included different health states such as MI, after MI, stroke, after stroke, and death. Drug acquisition cost and other direct medical costs were based on pricing records, literature, and expert panels. Clinical outcomes and utilities were based on literature. The model output included incremental cost-effectiveness ratio of quality-adjusted life-years (QALYs) and total costs per patient. Both 1-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were conducted.

FINDINGS

In the base-case scenario, the total costs of the treatment with clopidogrel and aspirin were ¥12,590 ($1849/€1590) and ¥10,642 ($1563/€1344), respectively; the total QALYs of the 2 patient populations were 9.7341 and 9.6894, respectively. The incremental cost-effectiveness ratio of ¥43,593 ($6402/€5515) per QALY gained was lower than 3 times of gross domestic product (GDP) per capita in China (¥161,940, $23,786/€20,449). Both 1-way sensitivity analysis and PSA confirmed the robustness of the results. PSA results indicated that clopidogrel was cost effective versus aspirin in 80.5% of the simulations, considering >3 times the GDP per capita as the threshold. Results in other scenarios (clopidogrel or aspirin for 2 or 3 years after 12-month DAPT) also indicated that clopidogrel was more cost effective than aspirin for patients with ACS after 12-month DAPT.

IMPLICATIONS

Compared with aspirin monotherapy, clopidogrel monotherapy for 1 year after 12-month DAPT was cost effective for patients with ACS who underwent PCI in China. Furthermore, when the duration of clopidogrel the monotherapy extended up to 3 years, clopidogrel was still cost effective compared with aspirin. The study was limited by lack of high-quality efficacy data among the Chinese population.

A Cost-effectiveness Analysis of Rabbit Antithymocyte Globulin Versus Antithymocyte Globulin-fresenius as Induction Therapy for Patients With Kidney Transplantation From Donation After Cardiac Death in China

PURPOSE

Induction immunosuppression therapy is used to support optimal outcomes in kidney transplantation. This study was to assess the cost-effectiveness of rabbit antithymocyte globulin (r-ATG) versus ATG-Fresenius (ATG-F) in kidney transplantation in the Chinese setting from the perspective of the health care payer.

METHODS

A 2-part survival model was developed, consisting of a short-term part and a long-term part. The short-term part analyzed the first year, using the decision tree, and consisted of the functioning transplant, acute rejection (AR), delayed graft function (DGF), dialysis, and death health states. The long-term part analyzed 2 to 5 years, using Markov model, and consisted of the functioning transplant, chronic dysfunction, recurring primary disease, dialysis, and death health states, with capture of the association between DGF and graft loss. Costs, including drug acquisition and other direct medical costs, were derived from China IQVIA database (formerly known as IMS) hospitaldatabase, chart review, and physician interviews. Clinical outcomes and utility were retrieved from published literature. The model calculated quality-adjusted life-years (QALYs) and total costs per patient. Costs and QALYs were discounted at an annual rate of 3.5%. Univariate sensitivity analysis and probability sensitivity analysis (PSA) were conducted to assess the impact of uncertainty of the variables on the results.

FINDINGS

Patients who received r-ATG had more clinical effectiveness than patients who received ATG-F mainly because of less AR, DGF, and dialysis. The incremental QALY was 0.01 over a 1-year time horizon and 0.0496 over a 5-year time horizon. R-ATG and ATG-F drug costs were ¥10,783 and ¥8409, respectively. However, the total treatment costs of the r-ATG arm were lower than the ATG-F arm because of lower costs related to DGF, AR, dialysis, and adverse events. In total, r-ATG saved ¥5423 over the 1-year and ¥7042 over the 5-year time horizon. R-ATG was dominant with lower total direct medical costs and higher QALYs compared with ATG-F. Both univariate sensitivity analysis and PSA found the robustness of the model results. PSA results indicated that r-ATG was cost-effective compared with ATG-F in 86.81% of the simulations, considering <3 times the gross domestic product per capita as the threshold.

IMPLICATIONS

From the perspective of the health care payer, r-ATG should be considered as the preferred treatment agent for induction therapy for Chinese patients undergoing kidney transplantation because of its lower overall medical costs and greater QALYs gained compared with ATG-F. The study was limited by lack of long-term efficacy data among the Chinese population and lack of comprehensive real-world higher quality costs data.

Economic evaluation of human urinary kallindinogenase for patients with acute ischemic stroke in China

OBJECTIVES

In China, both human urinary kallindinogenase (HUK) and 3-n-butylphthalide (NBP) are recommended for clinical use to improve cerebral blood circulation during an acute ischemic stroke (AIS). The objective was to evaluate the economic value of HUK vs NBP for patients with AIS from a Chinese payer's perspective.

METHODS

An economic evaluation based on data of patients who have been treated with either HUK (n = 488) or NBP (n = 885) from a prospective, phase IV, multi-center, clinical registry study (Chinese Acute Ischemic Stroke Treatment Outcome Registry, CASTOR) was conducted to analyze the cost and effectiveness of HUK vs NBP for AIS in China. Before the analysis, the patients were matched using propensity score. Both a cost-minimization analysis and a cost-effectiveness analysis were conducted to compare the matched pairs. A bootstrapping exercise was conducted for the matched arms to demonstrate the probability of one intervention being cost-effective over another for a given willingness-to-pay for an extra quality-adjusted life-year (QALY).

RESULTS

After propensity score matching, 463 pairs were matched. The overall medical cost in the HUK arm is USD 2,701.20, while the NBP arm is USD 3,436.83, indicating HUK is preferred with cost-minimization analysis. Although the QALY gained in the HUK arm (0.77176) compared with the NBP arm (0.76831) is statistically insignificant (p = .4862), the cost-effectiveness analysis as exploratory analysis found that, compared with NBP, HUK is a cost-saving strategy with the lower costs of USD 735.63 and greater QALYs gained of 0.00345. Among the 5,000 bootstrapping replications, 100% indicates that HUK is cost-effective compared with NBP under a 1-time-GDP threshold; and 97.12% indicates the same under a 3-time-GDP threshold.

CONCLUSION

This economic evaluation study indicates that administrating HUK is a cost-saving therapy compared with NBP for managing blood flow during AIS in the Chinese setting.

A Real-World Anti-Diabetes Medication Cost Comparison Between Premixed Insulin Analogs and Long-Acting Insulin Analogs in Chinese Patients with Type 2 Diabetes: A Retrospective Database Analysis

INTRODUCTION

To assess and compare per-day anti-diabetic medication costs for Chinese type-2 diabetes mellitus (T2DM) insulin-naïve patients between those who initiated premixed insulin analogs ("premixed group") and those who initiated long-acting insulin analogs ("long-acting group").

METHODS

Data were obtained from an electronic medical record database between 2010.01.01 and 2015.06.30 covering medical encounter records from all general hospitals in a district from Shanghai, China. Insulin-naïve T2DM patients who were aged ≥ 18 years, treated with an oral anti-diabetic drug (OAD) only during the baseline period (3 months prior to insulin initiation), and initiated premixed or long-acting insulin analogs were included. Patients were followed until index insulin discontinuation or 12 months after initiation, whichever came first. The t test and generalized linear models adjusting for propensity score (PS) (including baseline demographics, number of OAD classes, comorbidities, costs, and healthcare resource utilization) were used to examine the differences between the two insulin groups.

RESULTS

A total of 570 and 185 patients were identified for the premixed and long-acting groups, with mean (SD) ages of 63.0 (12.8) and 61.1 (11.9) (P = 0.08) and male proportions of 47.4% and 51.4% (P = 0.35), respectively. During the baseline period, 19.3% of the premixed users had T2DM-related hospitalizations, while the rate was 12.4% in the long-acting group (P = 0.03). The mean number of T2DM-related outpatient visits was 0.98 and 1.23 for the premixed and long-acting groups, respectively (P = 0.07). During the follow-up period, the per-day insulin dose averaged 31.7 and 15.3 international units (IU) for the premixed and long-acting groups, respectively. Compared with the patients on premixed insulin, the mean per-day cost for patients on long-acting insulin was 37.3% higher [15.3 vs 11.2 Chinese yuan (RMB); mean difference (MD) (95% CI): 4.2 (3.2, 5.1)] for the overall anti-diabetes medication, 81.3% higher [3.3 vs 1.8 RMB; MD (95% CI): 1.5 (0.8, 2.2)] for OAD, and 28.6% higher [12.0 vs 9.3 RMB; MD (95% CI): 2.7 (2.1, 3.3)] for insulin. The results were consistent after adjusting for the PS.

CONCLUSION

Among Chinese T2DM insulin-naïve patients, those who initiated premixed insulin had a lower per-day antidiabetic medication cost than those who initiated long-acting insulin.

FUNDING

Lilly Suzhou Pharmaceutical Co. Ltd, China.

Abstract P4-04-10: Molecular features of dormancy in ER+ breast cancers

Background:Late recurrence (emergence from dormancy) is characteristic of ER+ breast cancers. Despite adjuvant endocrine therapy, many breast cancers recur decades after their initial diagnosis and treatment. Why this occurs is poorly understood.

Methods: We studied 2 independent datasets of endocrine treated, ER+ breast cancers with up to 20 years follow-up. The 1st comprised matched samples from the primary tumor pretreatment at diagnosis and the first recurrence after or during adjuvant endocrine therapy (all FFPE). The 2nd dataset comprised pretreatment biopsies only (all snap frozen). For both datasets, high quality RNA was amplified, labelled, and subjected to transcriptome analysis using the Affymetrix technology (U133 Plus 2.0). Low quality data were identified using 'simpleaffy' and 'ffpe', and removed; all tools were from the R package unless otherwise noted. Remaining data were normalized using 'frma'. Genes differentially expressed between early (≤3 years) and late (≥ 5 years) were selected using limma. Unsupervised hierarchical clustering and PCA explored the structure of the data.

A similar molecular analysis was done on the 2nd dataset. A classification scheme that robustly separated early from late recurrences was validated in an independent public dataset of comparable patients, array platform, and frozen tissues. We also explored features in pretreatment samples that predetermined response duration.

Results: Genes that separated pretreatment specimens by recurrence time did not separate posttreatment specimens. Specimens did not cluster in patient pairs or by site of recurrence.

8245 genes were differentially expressed between early and late recurrences in the FFPE samples, while 2400 genes were significantly different in the same comparison in the frozen samples. Initial pathway analysis was done on each dataset independently using IPA (Ingenuity® Systems, www.ingenuity.com). 70 canonical pathways were identified in common between the two datasets (pretreatment). We then looked for genes regulated in both datasets (ignores FFPE and frozen tissue as source). There were 279 genes in common that differentially regulated in the same direction (upregulated; downregulated). IPA analysis of these genes identified 49 canonical pathways. We also explored the differentially expressed gene sets using 'GSEA' (www.software.broadinstitute.org/gsea/index.jsp). Pathways consistently associated with early vs. late recurrence include integrin signaling, the unfolded protein response, endoplasmic reticulum stress, actin-based motility, and estrogen biosynthesis.

Conclusion: Analysis of pretreatment tumors can predict early recurrences from those that will remain dormant and recur much later. Recurrent tumors exhibit a remodeled molecular landscape that likely reflects the effects of treatments and/or a recreation of a niche with potentially common features at the site of recurrence. Changes in molecular signaling associated with duration of recurrence are consistent with our experimental model studies in vitro implicating UPR signaling as a major integrator of response to endocrine therapy and duration of survival. Additional data sets are being arrayed and more detailed molecular signaling studies are in progress.

Citation Format: Clarke R, Dixon MJ, Jin L, Turnbull A, Hu R, Zwart A, Wang Y, Xuan J, Sengupta S, Renshaw L, Sims A, Liu MC. Molecular features of dormancy in ER+ breast cancers [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-04-10.

Economic Evaluation of Safflower Yellow Injection for the Treatment of Patients with Stable Angina Pectoris in China: A Cost-Effectiveness Analysis

OBJECTIVE

The purpose of this study was to evaluate the cost-effectiveness of Safflower Yellow Injection (SYI) plus conventional treatment (SYI group) versus conventional treatment only (conventional group) for the treatment of stable angina pectoris (SAP) patients in China.

METHODS

A decision-tree model was constructed and the treatment impact was estimated for up to 1 year. The data, including treatment effectiveness, episodes of angina pectoris (AP)-associated hospitalization and its in-hospital mortality, mortality rate of heart diseases, and cost of hospitalization, were obtained from literature. The costs of medications were calculated based on their average bidding prices in China. The authors also conducted a doctor survey to obtain cost associated with death of cardiovascular events. Sensitivity analysis was performed to evaluate the robustness of the results.

RESULTS

SAP patients in the SYI group (n = 1000) gained incremental 66.01 quality-adjusted life years (QALYs) at a cost of $250,294 compared with patients receiving conventional treatment, yielding an incremental cost-effectiveness ratio of $3,791/QALY, which was less than Chinese GDP per capita and is considered to be highly cost effective per WHO-recommended economic evaluation guidelines. Sensitivity analysis indicated that the results were robust with variations for all major parameters of the model.

CONCLUSION

SYI combined with conventional treatment is a highly cost-effective therapy option compared with the conventional treatment for treatment of SAP in China.

Pharmacoeconomic analysis for pemetrexed as a maintenance therapy for NSCLC patients with patient assistance program in China

OBJECTIVE

This study is to evaluate the costs, clinical efficacy, and social benefits of a patient assistance program (PAP) implemented by the China Primary Healthcare Foundation for the use of pemetrexed as a first-line non-squamous non-small cell lung cancer (NSCLC) maintenance therapy in China.

METHODS

A survival analysis was conducted on the clinical data of 1,366 patients who participated in the PAP. The progression-free survival (PFS) and median maintenance treatment cycle of pemetrexed were analyzed. A 36-month Markov model from a payer's perspective was constructed to analyze the cost and effectiveness associated with the PAP for pemetrexed. The inputs of the model were sourced from the PAP clinical database and published literature. The study estimated the incremental quality adjusted life-years (QALYs) (pemetrexed plus best supportive care [BSC] vs BSC only), the cost saving of the PAP, the impact on the percentage of catastrophic health expenditures (CHE), and poverty headcount ratio (HCR).

RESULTS

The median of PFS and maintenance treatment cycles were 187 days and five cycles (total nine cycles, which included four cycles of induction therapy), respectively. The pemetrexed plus BSC treatment with PAP resulted in an additional 0.12 QALYs over BSC only. The total cost was $48,034.46 and $96,191.57 for the patients who had or had not joined the PAP in 3 years, respectively. Compared to the patients without PAP, the percentage of CHE and HCR with PAP was reduced from 98.39% to 19.91% and 66.98% to 4.89%, respectively, indicating that the PAP substantially decreased the number of patients who had CHE and fallen into poverty.

CONCLUSION

The study concluded that the pemetrexed PAP generated noticeable clinical and economic benefits to society and to patients. The program also increased patients' compliance with chemotherapy by allowing patients, for whom the pemetrexed treatment was unaffordable, to continue to receive it.