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Gu J, Epland M, Ma X, Park J, Sanchez RJ, Li Y. A machine-learning algorithm using claims data to identify patients with homozygous familial hypercholesterolemia. Sci Rep 2024; 14:8890. [PMID: 38632285 PMCID: PMC11024086 DOI: 10.1038/s41598-024-58719-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
Homozygous familial hypercholesterolemia (HoFH) is an underdiagnosed and undertreated ultra-rare disease. We utilized claims data from the Komodo Healthcare Map database to develop a machine-learning model to identify potential HoFH patients. We tokenized patients enrolled in MyRARE (patient support program for those prescribed evinacumab-dgnb in the United States) and linked them with their Komodo claims. A true positive HoFH cohort (n = 331) was formed by including patients from MyRARE and patients with prescriptions for evinacumab-dgnb or lomitapide. The negative cohort (n = 1423) comprised patients with or at risk for cardiovascular disease. We divided the cohort into an 80% training and 20% testing set. Overall, 10,616 candidate features were investigated; 87 were selected due to clinical relevance and importance on prediction performance. Different machine-learning algorithms were explored, with fast interpretable greedy-tree sums selected as the final machine-learning tool. This selection was based on its satisfactory performance and its easily interpretable nature. The model identified four useful features and yielded precision (positive predicted value) of 0.98, recall (sensitivity) of 0.88, area under the receiver operating characteristic curve of 0.98, and accuracy of 0.97. The model performed well in identifying HoFH patients in the testing set, providing a useful tool to facilitate HoFH screening and diagnosis via healthcare claims data.
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Affiliation(s)
- Jing Gu
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
| | | | | | | | - Robert J Sanchez
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA.
| | - Ying Li
- Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, New York, NY, 10591, USA
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Murdock DJ, Wu N, Grimsby JS, Calle RA, Donahue S, Glass DJ, Sleeman MW, Sanchez RJ. The prevalence of low muscle mass associated with obesity in the USA. Skelet Muscle 2022; 12:26. [PMID: 36539856 PMCID: PMC9769063 DOI: 10.1186/s13395-022-00309-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sarcopenia is defined as age-related low muscle mass and function, and can also describe the loss of muscle mass in certain medical conditions, such as sarcopenic obesity. Sarcopenic obesity describes loss of muscle and function in obese individuals; however, as sarcopenia is an age-related condition and obesity can occur in any age group, a more accurate term is obesity with low lean muscle mass (OLLMM). Given limited data on OLLMM (particularly in those aged < 65 years), the purpose of this study was to estimate the prevalence of OLLMM in adults aged ≥ 20 years in the USA. METHODS Data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 and 1999-2006 were used. OLLMM was defined as an appendicular lean mass, adjusted for body mass index (BMI), cut-off point < 0.789 for males and < 0.512 for females, measured by dual-energy X-ray absorptiometry (DXA). DXA was only measured in individuals 20-59 years old in NHANES 2017-2018; we therefore utilized logistic regression models to predict OLLMM from NHANES 1999-2006 for those aged ≥ 60 years. The prevalence of OLLMM was estimated overall, and by sex, age, race/ethnicity, and clinical subgroup (high BMI, prediabetes, type 2 diabetes mellitus [T2DM], non-alcoholic fatty liver disease [NAFLD] with fibrosis, or post-bariatric surgery). Prevalence estimates were extrapolated to the USA population using NHANES sampling weights. RESULTS We estimated that, during 2017-2018, 28.7 million or 15.9% of the USA population had OLLMM. The prevalence of OLLMM was greater in older individuals (8.1%, aged 20-59 years vs 28.3%, aged ≥ 60 years), highest (66.6%) in Mexican-American females aged ≥ 60 years, and lowest (2.6%) in non-Hispanic Black males aged 20-59 years. There was a higher prevalence of OLLMM in adults with prediabetes (19.7%), T2DM (34.5%), NAFLD with fibrosis (25.4%), or post-bariatric surgery (21.8%), compared with those without each condition. CONCLUSIONS Overall, the burden of OLLMM in the USA is substantial, affecting almost 30 million adults. The prevalence of OLLMM increased with age, and among those with prediabetes, T2DM, NAFLD with fibrosis, or post-bariatric surgery. A unified definition of OLLMM will aid diagnosis and treatment strategies.
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Affiliation(s)
- Dana J. Murdock
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Ning Wu
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Joseph S. Grimsby
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Roberto A. Calle
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Stephen Donahue
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - David J. Glass
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Mark W. Sleeman
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
| | - Robert J. Sanchez
- grid.418961.30000 0004 0472 2713Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY 10591-6707 USA
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Hussein M, Wei W, Mastey V, Sanchez RJ, Wang D, Murdock DJ, Hirshberg B, Weinreich DM, Jalbert JJ. Real-world effectiveness of casirivimab and imdevimab among patients diagnosed with COVID-19 in the ambulatory setting: a retrospective cohort study using a large claims database. BMJ Open 2022; 12:e064953. [PMID: 36535724 PMCID: PMC9764096 DOI: 10.1136/bmjopen-2022-064953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess the real-world effectiveness of casirivimab and imdevimab (CAS+IMD) versus no COVID-19 antibody treatment among patients diagnosed with COVID-19 in the ambulatory setting, including patients diagnosed during the Delta-dominant period prior to Omicron emergence. DESIGN Retrospective cohort study. SETTING Komodo Health closed claims database. PARTICIPANTS 13 273 128 patients diagnosed with COVID-19 (December 2020 through September 2021) were treated with CAS+IMD or untreated but treatment eligible under the Emergency Use Authorization (EUA). Each treated patient was exact and propensity score matched without replacement to up to five untreated EUA-eligible patients. INTERVENTIONS CAS+IMD. PRIMARY AND SECONDARY OUTCOME MEASURES Composite endpoint of 30-day all-cause mortality or COVID-19-related hospitalisation. Kaplan-Meier estimators were used to calculate outcome risks overall and across subgroups: age, COVID-19 vaccination status, immunocompromised status, and timing of diagnosis (December 2020 to June 2021, and July to September 2021). Cox proportional hazards models were used to estimate adjusted HRs (aHRs) and 95% CIs. RESULTS Among 75 159 CAS+IMD-treated and 1 670 338 EUA-eligible untreated patients, 73 759 treated patients were matched to 310 688 untreated patients; matched patients were ~50 years, ~60% were women and generally well balanced across risk factors. The 30-day risk of the composite outcome was 2.1% and 5.2% in the CAS+IMD-treated and CAS+IMD-untreated patients, respectively; equivalent to a 60% lower risk (aHR 0.40; 95% CI, 0.38 to 0.42). The effect of CAS+IMD was consistent across subgroups, including those who received a COVID-19 vaccine (aHR 0.48, 95% CI, 0.41 to 0.56), and those diagnosed during the Delta-dominant period (aHR 0.40, 95% CI, 0.38 to 0.42). CONCLUSIONS The real-world effectiveness of CAS+IMD is consistent with the efficacy for reducing all-cause mortality or COVID-19-related hospitalisation reported in clinical trials. Effectiveness is maintained across patient subgroups, including those prone to breakthrough infections, and was effective against susceptible variants including Delta. .
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Affiliation(s)
| | - Wenhui Wei
- Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA
| | - Vera Mastey
- Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA
| | | | - Degang Wang
- Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA
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Jalbert JJ, Hussein M, Mastey V, Sanchez RJ, Wang D, Murdock D, Fariñas L, Bussey J, Duart C, Hirshberg B, Weinreich DM, Wei W. Effectiveness of Subcutaneous Casirivimab and Imdevimab in Ambulatory Patients with COVID-19. Infect Dis Ther 2022; 11:2125-2139. [PMID: 36181639 PMCID: PMC9526200 DOI: 10.1007/s40121-022-00691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/22/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Data on real-world effectiveness of subcutaneous (SC) casirivimab and imdevimab (CAS+IMD) for the treatment of coronavirus disease 2019 (COVID-19) are limited. The objective of this study was to assess the effectiveness of SC CAS+IMD versus no antibody treatment among patients with COVID-19. METHODS This retrospective cohort study linked Komodo Health and CDR Maguire Health and Medical data. Patients diagnosed with COVID-19 in ambulatory settings (August 1-October 30, 2021) treated with SC CAS+IMD were exact- and propensity score-matched to fewer than five untreated treatment-eligible patients and followed for the composite endpoint of 30-day all-cause mortality or COVID-19-related hospitalization. Kaplan-Meier estimators were used to calculate outcome risk overall and across subgroups. Cox proportional-hazards models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS Of 13,522 patients treated with CAS+IMD, 12,972 were matched to 41,848 untreated patients. The 30-day composite outcome risk was 1.9% (95% CI 1.7-2.2) and 4.4% (95% CI 4.2-4.6) in the treated and untreated cohorts, respectively; treated patients had a 49% lower relative risk of the composite outcome (aHR 0.51; 95% CI 0.46-0.58) and a 67% relative risk of 30-day mortality (aHR 0.33, 95% CI 0.18-0.60). Effectiveness was consistent across vaccination status and various subgroups. DISCUSSION Patients with COVID-19 benefitted from treatment with SC CAS+IMD versus untreated patients. The results were consistent across subgroups of patients, including older adults, immunocompromised patients, and patients vaccinated against COVID-19. Results were robust across numerous sensitivity analyses. CONCLUSION SC CAS+IMD is effective in reducing 30-day COVID-19-related hospitalization or mortality in real-world outpatient settings during the Delta-dominant period.
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Affiliation(s)
- Jessica J Jalbert
- Regeneron Pharmaceuticals, Inc., 1 Rockwood Road, Sleepy Hollow, NY, 10510, USA.
| | | | - Vera Mastey
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - Degang Wang
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Dana Murdock
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | | | | | | | | | - Wenhui Wei
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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Martin SA, Sanchez RJ, Olayinka-Amao O, Harris C, Fehnel S. Qualitative interviews in patients with lipodystrophy to assess the patient experience: evaluation of hunger and other symptoms. J Patient Rep Outcomes 2022; 6:84. [PMID: 35904713 PMCID: PMC9338178 DOI: 10.1186/s41687-022-00486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background New treatments are being evaluated for lipodystrophy; however, limited information is available on the patient experience. Results of a prior patient panel showed that hunger and temperature-related symptoms were an issue for participants. Therefore, evaluation of any changes in these symptoms is recommended for inclusion in new treatment options. The objective of this study was to further understand the patient experience and to evaluate newly developed items of hunger and temperature regulation. Methods Individual, in-depth telephone interviews were conducted via semi-structured discussion guide. Telephone interviews were conducted with 21 US patients with generalized lipodystrophy (GLD) or partial lipodystrophy (PLD). Eligibility requirements included self-reported PLD or GLD. Interviews included open-ended concept elicitation followed by a review of newly developed items assessing hunger, temperature sensations, and patient globals. Interviews were conducted in two rounds, with the newly developed items assessing hunger revised after each round of interviews based on participant feedback. Results Results indicated that hunger-related symptoms were considered a current issue for greater than half (N = 11) of participants, and all but one reported this as an issue at some point in their lives. Specifically, participants most often reported symptoms of increased appetite and not feeling full. The cognitive debriefing process indicated that the hunger-related symptoms, temperature, and global impression of change and severity items were correctly interpreted and easily completed by the participants. While not a focus of the interviews, the concept elicitation results demonstrated that pain was a frequently reported and bothersome symptom in this patient population. Conclusions This qualitative research provided evidence to support the use of clinical outcomes assessments such as hunger and temperature-related items in clinical trials. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00486-3.
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Murdock DJ, Sanchez RJ, Mohammadi KA, Fazio S, Geba GP. Serum cholesterol and the risk of developing hormonally driven cancers: A narrative review. Cancer Med 2022; 12:6722-6767. [PMID: 36444895 PMCID: PMC10067100 DOI: 10.1002/cam4.5463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/18/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022] Open
Abstract
Although cholesterol has been hypothesized to promote cancer development through several potential pathways, its role in the risk of developing hormonally driven cancer is controversial. This literature review summarizes evidence from the highest quality studies to examine the consistency and strength of the relationship between serum cholesterol parameters and incidence of hormonally driven cancer. Articles were identified using EMBASE. Longitudinal observational studies published between January 2000 and December 2020 were considered for inclusion. The endpoint of interest was incident prostate, ovary, breast, endometrium, and uterine cancers. In total, 2732 reports were identified and screened; 41 studies were included in the review. No associations were found for ovarian cancer. Most endometrial cancer studies were null. The majority (76.9%) of studies reported no association between cholesterol and prostate cancer. Data on breast cancer were conflicting, associations limited, and effect sizes modest. Our results do not provide evidence for a clear association between cholesterol and different types of incident, hormonally driven reproductive cancers. Future studies should investigate the impact of lipid-lowering therapy.
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Affiliation(s)
- Dana J Murdock
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | | | | | - Sergio Fazio
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Gregory P Geba
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
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Gu J, Sanchez RJ, Chauhan A, Fazio S, Rosenson RS. Simulation of lipid-lowering therapy (LLT) intensification in very high-risk patients with atherosclerotic cardiovascular disease. J Clin Lipidol 2022; 16:901-905. [DOI: 10.1016/j.jacl.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/10/2022] [Accepted: 10/05/2022] [Indexed: 11/08/2022]
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Sanchez RJ, Ge W, Wei W, Ponda MP, Rosenson RS. The association of triglyceride levels with the incidence of initial and recurrent acute pancreatitis. Lipids Health Dis 2021; 20:72. [PMID: 34275452 PMCID: PMC8286611 DOI: 10.1186/s12944-021-01488-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background This retrospective cohort study assessed the annualized incidence rate (IR) of acute pancreatitis (AP) in a nationally representative US adult population, as well as the variation in the risk of AP events across strata of triglyceride (TG) levels. Methods Data were obtained from IQVIA’s US Ambulatory Electronic Medical Records (EMR) database linked with its LRxDx Open Claims database. Inclusion criteria included ≥1 serum TG value during the overlapping study period of the EMR and claims databases, ≥1 claim in the 12-month baseline period, and ≥ 1 claim in the 12 months post index. All TG measurements were assigned to the highest category reached: < 2.26, ≥2.26 to ≤5.65, > 5.65 to ≤9.94, > 9.94, and > 11.29 mmol/L (< 200, ≥200 to ≤500, > 500 to ≤880, > 880, and > 1000 mg/dL, respectively). The outcome of interest was AP, defined as a hospitalization event with AP as the principal diagnosis. Results In total, 7,119,195 patients met the inclusion/exclusion criteria, of whom 4158 (0.058%) had ≥1 AP events in the prior 12 months. Most patients (83%) had TGs < 2.26 mmol/L (< 200 mg/dL), while < 1% had TGs > 9.94 mmol/L (> 880 mg/dL). Overall, the IR of AP was low (0.08%; 95% confidence internal [CI], 0.08–0.08%), but increased with increasing TGs (0.08% in TGs < 2.26 mmol/L [< 200 mg/dL] to 1.21% in TGs > 11.29 mmol/L [> 1000 mg/dL]). In patients with a prior history of AP, the IR of AP increased dramatically; patients with ≥2 AP events at baseline had an IR of 29.98% (95% CI, 25.1–34.9%). Conclusion The risk of AP increases with increasing TG strata; however, the risk increases dramatically among patients with a recent history of AP.
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Affiliation(s)
| | - Wenzhen Ge
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Wenhui Wei
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Manish P Ponda
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, One Gustav L. Levy Place, Hospital Box 1030, New York, NY, 10029, USA.
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Dahir KM, Mcginniss J, Mellis S, Sanchez RJ, Rocco MD, Keen R, Orcel P, Funck-Brentano T, Roux C, Kolta S, Madeo A, Bubbear JS, Tabarkiewicz J, Szczepanek M, Bachiller-Corral J, Cheung AM, Botman E, Mukaddam MA, Tile L, Portal-Celhay C, Sarkar N, Hou P, Forleo-Neto E, Rankin AJ, Economides AN, Trotter DG, Eekhoff EMW, Kaplan FS, Pignolo RJ. Garetosmab Reduces Flare-ups in Patients With Fibrodysplasia Ossificans Progressiva. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, autosomal dominant disorder driven by mutations in ACVR1 that render it responsive to Activin A. FOP is characterized by progressive heterotopic ossification (HO) and distressing inflammatory events called “flare-ups.” Flare-ups can precede new HO; however, limited prospective data exists on this phenomenon. Garetosmab (GAR), an investigational human monoclonal antibody against Activin A, blocks formation of new HO in FOP. Methods: This is a post-hoc analysis of LUMINA-1 (NCT03188666) a phase 2, randomized, double-blind, placebo-controlled study, which evaluated the safety and efficacy of GAR (10 mg/kg/week IV) versus placebo (PBO) in adult patients with FOP over 28 weeks. Patient-reported flare-ups were collected via a patient diary and severity level was reported as mild, moderate or severe. Clinician-reported flare-ups were collected as adverse events in the trial. HO lesions were imaged by 18F-NaF positron emission tomography (PET) and whole-body low-dose X-ray computed tomography (CT). Results: There was a two-fold higher proportion of patients who reported one or more flare-ups on PBO 17/24 (71%) compared with GAR 7/20 (35%). Clinicians reported a four-fold higher proportion of patients experiencing one or more flare-ups on PBO 10/24 (42%) compared with GAR 2/20 (10%). Overall rates of flare-up events were two-fold higher on PBO vs. GAR (1.4 vs. 0.65 events/patient/28 weeks) for patient-reported events and eight-fold higher on PBO vs. GAR by clinician report (0.83 vs. 0.10 events/patient/28 weeks). Most flare-ups occurred on the extremities and back; pain was the most commonly reported symptom. Patient-reported flare-ups on PBO were more frequently reported as severe (29.4%) compared with GAR (7.7%). Among subjects with at least 12 weeks of follow-up from start of patient-reported flare-up, development of new HO near the site was 5/27 (18.5%) on PBO and (0%) on GAR. Of all new HO lesions, 41% on PBO and 0% on GAR occurred with spatial and temporal relation to flare-up. Conclusions: Approximately two-thirds of patients on PBO reported flare-ups over 28 weeks. GAR was associated with reductions in frequency and severity of flare-ups. Fewer than 20% of patient-reported flare-ups were associated with new HO, indicating frequent discordance of these phenomena, and compatible with previous reports. GAR’s ability to reduce patient- and clinician-reported flare-ups, as well as new HO lesions may provide an important therapeutic option.
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Affiliation(s)
| | | | | | | | | | - Richard Keen
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | - Philippe Orcel
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Thomas Funck-Brentano
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Christian Roux
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sami Kolta
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Judith S Bubbear
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | | | | | | | | | - Esmée Botman
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, Netherlands
| | - Mona Al Mukaddam
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | | | - E Marelise W Eekhoff
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, Netherlands
| | - Frederick S Kaplan
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Bhatt DL, Briggs AH, Reed SD, Annemans L, Szarek M, Bittner VA, Diaz R, Goodman SG, Harrington RA, Higuchi K, Joulain F, Jukema JW, Li QH, Mahaffey KW, Sanchez RJ, Roe MT, Lopes RD, White HD, Zeiher AM, Schwartz GG, Gabriel Steg P. Cost-Effectiveness of Alirocumab in Patients With Acute Coronary Syndromes: The ODYSSEY OUTCOMES Trial. J Am Coll Cardiol 2020; 75:2297-2308. [PMID: 32381160 DOI: 10.1016/j.jacc.2020.03.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/06/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cholesterol reduction with proprotein convertase subtilisin-kexin type 9 inhibitors reduces ischemic events; however, the cost-effectiveness in statin-treated patients with recent acute coronary syndrome remains uncertain. OBJECTIVES This study sought to determine whether further cholesterol reduction with alirocumab would be cost-effective in patients with a recent acute coronary syndrome on optimal statin therapy. METHODS A cost-effectiveness model leveraging patient-level data from ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was developed to estimate costs and outcomes over a lifetime horizon. Patients (n = 18,924) had a recent acute coronary syndrome and were on high-intensity or maximum-tolerated statin therapy, with a baseline low-density lipoprotein cholesterol (LDL-C) level ≥70 mg/dl, non-high-density lipoprotein cholesterol ≥100 mg/dl, or apolipoprotein B ≥80 mg/l. Alirocumab 75 mg or placebo was administered subcutaneously every 2 weeks. Alirocumab was blindly titrated to 150 mg if LDL-C remained ≥50 mg/dl or switched to placebo if 2 consecutive LDL-C levels were <15 mg/dl. Incremental cost per quality-adjusted life-year (QALY) was determined with the addition of alirocumab versus placebo and, based on clinical efficacy findings from the trial, was stratified by baseline LDL-C levels ≥100 mg/dl and <100 mg/dl. RESULTS Across the overall population recruited to the ODYSSEY OUTCOMES trial, using an annual treatment cost of US$5,850, the mean overall incremental cost-effectiveness ratio was US$92,200 per QALY (base case). The cost was US$41,800 per QALY in patients with baseline LDL-C ≥100 mg/dl, whereas in those with LDL-C <100 mg/dl the cost per QALY was US$299,400. Among patients with LDL-C ≥100 mg/dl, incremental cost-effectiveness ratios remained below US$100,000 per QALY across a wide variety of sensitivity analyses. CONCLUSIONS In patients with a recent acute coronary syndrome on optimal statin therapy, alirocumab improves cardiovascular outcomes at costs considered intermediate value, with good value in patients with baseline LDL-C ≥100 mg/dl but less economic value with LDL-C <100 mg/dl. (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab [ODYSSEY OUTCOMES]; NCT01663402).
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Affiliation(s)
- Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Andrew H Briggs
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Michael Szarek
- Downstate School of Public Health, State University of New York, Brooklyn, New York
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert A Harrington
- Department of Medicine, Stanford University Medical Center, Stanford, California
| | | | | | | | | | - Kenneth W Mahaffey
- Department of Medicine, Stanford University Medical Center, Stanford, California
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Harvey D White
- Green Lane Cardiovascular Services Auckland City Hospital, Auckland, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ph Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, French Alliance for Cardiovascular Trials, Institut National de la Santé et de la Recherche Médicale U1148, Paris, France; National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom. https://twitter.com/gabrielsteg
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11
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Burbridge C, Randall JA, Sanchez RJ, Dansky H, Symonds T, Girman CJ, Strayer JA, Selk KL, Whitcomb DC, Kershaw EE. Symptoms and Dietary Impact in Hypertriglyceridemia-Associated Pancreatitis: Development and Content Validity of Two New Measures. Pharmacoecon Open 2020; 4:191-201. [PMID: 31250380 PMCID: PMC7018925 DOI: 10.1007/s41669-019-0155-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Severe hypertriglyceridemia (sHTG) is a rare condition, complicated by episodes of acute pancreatitis (AP), which can cause pain and/or life-threatening multi-organ dysfunction. Currently, there are no disease-specific patient-reported outcome (PRO) measures evaluating symptoms or dietary impact for this condition. OBJECTIVE The objective of this study was to explore patient-reported symptoms and impacts of sHTG and AP and develop new measures to capture the symptoms and dietary impacts of this condition using patient language. METHODS In-depth, semi-structured concept elicitation interviews were conducted with 12 US-based participants to explore their experience and identify key symptoms and impact on dietary behavior, both during and between episodes of AP. Participants had a range of AP severity with a previous triglyceride reading > 1000 mg/dL, and at least one attack of AP within the last 12 months. Transcripts were coded using thematic analysis. RESULTS Qualitative data analysis revealed the substantial burden of AP associated with sHTG. Participants reported experiencing symptoms, especially abdominal pain, both during and between attacks of AP, and discussed considerable diet changes to prevent or minimize future attacks. A conceptual model was refined, based on patient input, and reviewed by clinical experts to determine key concepts for inclusion within two PRO measures, one evaluating symptoms and another evaluating impact on dietary behavior. Items were drafted using patient-derived language. A 19-item symptoms measure [Hypertriglyceridemia and Acute Pancreatitis Symptom Scale (HAP-SS)] and a 6-item dietary impact measure (Hypertriglyceridemia and Acute Pancreatitis Dietary Behavior (HAP-DB) measure) were developed, both with a 24-h recall period. CONCLUSIONS The qualitative analysis confirmed the substantial burden of AP associated with sHTG. This research resulted in development of two disease-specific PRO measures for use during and between attacks of AP. These measures are being utilized in a clinical trial, which will confirm content, structure, and psychometric properties.
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Affiliation(s)
- Claire Burbridge
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
| | - Jason A. Randall
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
| | | | | | - Tara Symonds
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
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12
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Navar AM, Peterson ED, Steen DL, Wojdyla DM, Sanchez RJ, Khan I, Song X, Gold ME, Pencina MJ. Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research. JAMA Cardiol 2020; 4:375-379. [PMID: 30840023 DOI: 10.1001/jamacardio.2019.0198] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Despite its documented undercapture of mortality data, the US Social Security Administration Death Master File (SSDMF) is still often used to provide mortality end points in retrospective clinical studies. Changes in death data reporting to SSDMF in 2011 may have further affected the reliability of mortality end points, with varying consequences over time and by state. Objective To evaluate the reliability of mortality rates in the SSDMF in a cohort of patients with atherosclerotic cardiovascular disease (ASCVD). Design, Setting, and Participants This observational analysis used the IBM MarketScan Medicare and commercial insurance databases linked to mortality information from the SSDMF. Adults with ASCVD who had a clinical encounter between January 1, 2012, and December 31, 2013, at least 2 years of follow-up, and from states with 1000 or more eligible adults with ASCVD were included in the study. Data analysis was conducted between April 18 and May 21, 2018. Main Outcomes and Measures Kaplan-Meier analyses were conducted to estimate state-level mortality rates for adults with ASCVD, stratified by database (commercial or Medicare). Constant hazards of mortality by state were tested, and individual state Kaplan-Meier curves for temporal changes were evaluated. For states in which the hazard of death was constant over time, mortality rates for adults with ASCVD were compared with state-level, age group-specific overall mortality rates in 2012, as reported by the National Center for Health Statistics (NCHS). Results This study of mortality data of 667 516 adults with ASCVD included 274 005 adults in the commercial insurance database cohort (171 959 male [62.8%] and median [interquartile range (IQR)] age of 58 [52-62] years) and 393 511 in the Medicare database cohort (245 366 male [62.4%] and median [IQR] age of 76 [70-83] years). Of the 41 states included, 11 states (26.8%) in the commercial cohort and 18 states (43.9%) in the Medicare cohort had a change in the hazard of death after 2012. Among states with constant hazard, state-level mortality rates using the SSDMF ranged widely, from 0.06 to 1.30 per 100 person-years (commercial cohort) and from 0.83 to 6.07 per 100 person-years (Medicare cohort). Variability between states in mortality estimates for adults with ASCVD using SSDMF data greatly exceeded variability in overall mortality from the NCHS. No correlation was found between NCHS mortality estimates and those from the SSDMF (ρ = 0.29 [P = .06] for age 55-64 years; ρ = 0.18 [P = .27] for age 65-74 years). Conclusions and Relevance The SSDMF appeared to markedly underestimate mortality rates, with variable undercapture among states and over time; this finding suggests that SSDMF data are not reliable and should not be used alone by researchers to estimate mortality rates.
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Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Associate Editor
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Dylan L Steen
- Associate Editor.,Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Xue Song
- IBM Watson Health, Cambridge, Massachusetts
| | - Matthew E Gold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Deputy Editor for Statistics
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13
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Rana JS, Liu JY, Moffet HH, Sanchez RJ, Khan I, Karter AJ. Risk of Cardiovascular Events in Patients With Type 2 Diabetes and Metabolic Dyslipidemia Without Prevalent Atherosclerotic Cardiovascular Disease. Am J Med 2020; 133:200-206. [PMID: 31344341 DOI: 10.1016/j.amjmed.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The relationship between achieved low-density lipoprotein cholesterol (LDL-C) levels and risk of incident atherosclerotic cardiovascular disease events among patients with diabetes and metabolic dyslipidemia has not been well described. METHODS We conducted an observational cohort study of statin-treated adults (ages 21-90 years) with type 2 diabetes without established atherosclerotic cardiovascular disease (as of January 1, 2006) who had metabolic dyslipidemia (elevated triglycerides ≥150 mg/dL and low high-density lipoprotein cholesterol, <50 mg/dL [women] and <40 mg/dL [men]). All subjects were members of Kaiser Permanente Northern California, an integrated health care delivery system. Adjusted multivariable Cox models were specified to estimate hazard ratios (HRs) for incident atherosclerotic cardiovascular disease events by achieved LDL-C levels (<50, 50-<70, 70-<100, and ≥100 mg/dL). Incident atherosclerotic cardiovascular disease events were defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through December 31, 2013. RESULTS A total of 19,095 individuals met the selection criteria. Mean age was 63.4 years, 53.5% were women, and the mean follow-up was 5.9 years. Unadjusted rates of atherosclerotic cardiovascular disease events were not significantly different across specified LDL-C categories. In models adjusted for demographics and clinical characteristics, the risk was significantly lower with decreasing achieved LDL-C levels (P <0.0001 for trend). Relative to achieved LDL-C ≥100 mg/dL, LDL-C <50 mg/dL had an hazard ratio of 0.66 (95% confidence interval [CI] 0.52-0.82). CONCLUSION In a large, contemporary cohort of statin-treated patients with type 2 diabetes and metabolic dyslipidemia without established atherosclerotic cardiovascular disease, lower achieved LDL-C levels were associated with a monotonically lower risk of incident atherosclerotic cardiovascular disease events. The benefits of achieving very-low LDL-C (<50 mg/dL) in this population requires further evaluation in prospective interventional studies.
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Affiliation(s)
- Jamal S Rana
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, Calif; Department of Medicine, University of California, San Francisco; Division of Research, Kaiser Permanente Northern California, Oakland, Calif.
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Robert J Sanchez
- Health Economics and Outcomes Research, Medical Affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | - Irfan Khan
- Real-World Evidence and Clinical Outcomes, Sanofi, Bridgewater, NJ
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
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14
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Abstract
Supplemental Digital Content is available in the text. Background: To optimize preventive strategies for coronary heart disease (CHD), it is essential to understand and appropriately quantify the contribution of its key risk factors. Our objective was to compare the associations of key modifiable CHD risk factors—specifically lipids, systolic blood pressure (SBP), diabetes mellitus, and smoking—with incident CHD events based on their prognostic performance, attributable risk fractions, and treatment benefits, overall and by age. Methods: Pooled participant-level data from 4 observational cohort studies sponsored by the National Heart, Lung, and Blood Institute were used to create a cohort of 22 626 individuals aged 45 to 84 years who were initially free of cardiovascular disease. Individuals were followed for 10 years from baseline evaluation for incident CHD. Proportional hazards regression was used to estimate metrics of prognostic model performance (likelihood ratio, C index, net reclassification, discrimination slope), hazard ratios, and population attributable fractions for SBP, non–high-density lipoprotein cholesterol (non–HDL-C), diabetes mellitus, and smoking. Expected absolute risk reductions for antihypertensive and lipid-lowering treatment were assessed. Results: Age, sex, and race capture 63% to 80% of the prognostic performance of cardiovascular risk models. In contrast, adding either SBP, non–HDL-C, diabetes mellitus, or smoking to a model with other risk factors increases the C index by only 0.004 to 0.013. However, primordial prevention could have a substantial effect as demonstrated by population attributable fractions of 28% for SBP≥130 mm Hg and 17% for non–HDL-C≥130 mg/dL. Similarly, lowering the SBP of all individuals to <130 mm Hg or lowering low-density lipoprotein cholesterol by 30% would be expected to lower a baseline 10-year CHD risk of 10.7% to 7.0 and 8.0, respectively (absolute risk reductions: 3.7% and 2.7%, respectively). Prognostic performance decreases with age (C indices for age groups 45–54, 55–64, 65–74, 75–84 are 0.75, 0.72, 0.66, and 0.62, respectively), whereas absolute risk reductions increase (SBP: 1.1%, 2.3%, 5.4%, 10.3%, respectively; non–HDL-C: 1.1%, 2.0%, 3.7%, 5.9%, respectively). Conclusions: Although individual modifiable CHD risk factors contribute only modestly to prognostic performance, our models indicate that eliminating or controlling these individual factors would lead to substantial reductions in total population CHD events. Metrics used to judge importance of risk factors should be tailored to the research objectives.
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Affiliation(s)
- Michael J Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | | | - Irfan Khan
- Real-World Evidence and Clinical Outcomes, Sanofi, Bridgewater, NJ (I.K.)
| | - Joseph Elassal
- Regeneron Pharmaceuticals Inc, Tarrytown, NY (R.J.S., J.E.)
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, MA (R.B.D.).,Baim Institute for Clinical Research, Boston, MA (R.B.D.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.J.P., A.M.N., D.W., E.D.P.)
| | - Allan D Sniderman
- Mike Rosenbloom Laboratory for Cardiovascular Research, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada (A.D.S.)
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15
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Cannon CP, Khan I, Klimchak AC, Sanchez RJ, Sasiela WJ, Massaro JM, D'Agostino RB, Reynolds MR. Simulation of impact on cardiovascular events due to lipid-lowering therapy intensification in a population with atherosclerotic cardiovascular disease. Am Heart J 2019; 216:30-41. [PMID: 31386936 DOI: 10.1016/j.ahj.2019.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 06/05/2019] [Indexed: 11/24/2022]
Abstract
In patients with atherosclerotic cardiovascular disease (ASCVD), guidelines recommend statins as first-line lipid-lowering therapy (LLT) with addition of nonstatin agents in those with persistently elevated low-density lipoprotein cholesterol levels. METHODS To estimate the cardiovascular (CV) risk reduction implications of treatment intensification, we used a previously reported simulation model with enhancements. An ASCVD cohort was developed from a US claims database. A Cox model was used to estimate baseline risk of CV events: myocardial infarction, ischemic stroke, unstable angina hospitalization, elective coronary revascularization, or cardiovascular death. Patients were sampled with replacement (bootstrapping) and entered the simulation model, which applied stepwise LLT intensification logic, with a goal of achieving low-density lipoprotein cholesterol less than 70 mg/dL at each step. CV risk reduction assumptions were based on published data. Two treatment intensification scenarios were investigated: ideal and real-world (which accounted for statin intolerance, nonadherence, and payer restrictions). RESULTS In a cohort of 1,000 patients with ASCVD, approximately 813 (809-818) would require treatment intensification with LLT under an ideal treatment intensification scenario. Before treatment intensification, 183 (179-187) events would be expected to occur over 5 years. With treatment intensification, 40 (34-45) of these events could be avoided. In a real-world scenario, about 818 (813-823) patients require treatment intensification with LLT, resulting in 29 (24-34) events avoided over 5 years. CONCLUSIONS Intensification of LLT in an ASCVD population translates into a substantial number of CV events avoided. This simulation-based model could assist in assessing the potential benefits of various types of population-level LLT interventions.
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16
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Bradley CK, Shrader P, Sanchez RJ, Peterson ED, Navar AM. The patient journey with proprotein convertase subtilisin/kexin type 9 inhibitors in community practice. J Clin Lipidol 2019; 13:725-734. [PMID: 31371271 DOI: 10.1016/j.jacl.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/14/2019] [Accepted: 06/21/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Trials have demonstrated that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are effective as an adjunct to statin therapy, but access and cost issues have limited their use in community practice. OBJECTIVE The aim of the study was to better understand patients' experiences when trying to obtain, fill, and use PCSK9 inhibitor therapy in community practice. METHODS We conducted a patient survey to evaluate patient experiences with PCSK9 inhibitors including medication initiation, indication for treatment, insurance approval status, medication persistence, and reason for discontinuation. The survey was emailed to 4740 adults who used a patient access support program. RESULTS Overall, 1327 of 4740 adults completed the survey (28.0% response rate). Of those, 75.0% were aged >60 years, 52.8% were male, and 92.4% were White. At the time of PCSK9 inhibitor prescription, 70.2% were not on a statin (with 84.4% of those not on a statin reporting statin intolerance). Overall, 74.6% of patients found the drug approval process to be "somewhat" or "very" burdensome. Among n = 1216 patients who initiated treatment, 33.7% discontinued by the time of the survey, with 50.0% taking the drug for 1 to 6 months. Patient out-of-pocket costs were the leading reported reason for discontinuation. CONCLUSIONS Most PCSK9 inhibitor users in community practice were not on a statin, presumably because of statin intolerance. The drug approval process and costs continue to be strong reasons for lower initiation of PCSK9 agents, as well as higher discontinuation rates.
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Affiliation(s)
- Corey K Bradley
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Peter Shrader
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Sanchez
- Medical Affairs, Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Cannon CP, Khan I, Klimchak AC, Reynolds MR, Sanchez RJ, Sasiela WJ. Simulation of Lipid-Lowering Therapy Intensification in a Population With Atherosclerotic Cardiovascular Disease. JAMA Cardiol 2019; 2:959-966. [PMID: 28768335 DOI: 10.1001/jamacardio.2017.2289] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Importance In patients with atherosclerotic cardiovascular disease (ASCVD), guidelines recommend optimizing statin treatment, and consensus pathways suggest use of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in patients with persistently elevated low-density lipoprotein cholesterol (LDL-C) levels despite use of statins. Recent trials have provided evidence of benefit in reduction of cardiovascular events with these agents. Objective To estimate the percentage of patients with ASCVD who would require a PCSK9 inhibitor when oral lipid-lowering therapy (LLT) is intensified first. Design, Setting, and Participants This simulation model study used a large administrative database of US medical and pharmacy claims to identify a cohort of 105 269 patients with ASCVD enrolled from January 1, 2012, through December 31, 2013, who met the inclusion criteria (database cohort). Patients were sampled with replacement (bootstrapping) to match the US epidemiologic distribution and entered into a Monte Carlo simulation (simulation cohort) that applied stepwise treatment intensification algorithms in those with LDL-C levels of at least 70 mg/dL. All patients not initially receiving a statin were given atorvastatin, 20 mg, and the following LLT intensification steps were applied: uptitration to atorvastatin, 80 mg; add-on ezetimibe therapy; add-on alirocumab therapy, 75 mg (a PCSK9 inhibitor); and uptitration to alirocumab, 150 mg. Sensitivity analyses included evolocumab as a PCSK9 inhibitor. Efficacy was estimated from published studies and incorporated patient-level variation. Data were analyzed from December 2015 to May 2017. Exposures Treatment intensification strategies with LLT. Main Outcomes and Measures Use of LLT among the population with ASCVD and distributions of LDL-C levels under various treatment intensification scenarios. Results Inclusion criteria were met by 105 269 individuals in the database cohort (57.2% male and 42.8% female; mean [SD] age, 65.1 [12.1] years). In the simulation cohort (1 million patients; 54.8% male and 45.2% female; mean [SD] age, 66.4 [12.2] years), before treatment intensification, 51.5% used statin monotherapy and 1.7% used statins plus ezetimibe. Only 25.2% achieved an LDL-C level of less than 70 mg/dL. After treatment intensification, 99.3% could achieve an LDL-C level of less than 70 mg/dL, including 67.3% with statin monotherapy, 18.7% with statins plus ezetimibe, and 14% with add-on PCSK9 inhibitor. Conclusions and Relevance Large gaps exist between recommendations and current practice regarding LLT in the population with ASCVD. In our model that assumes no LLT intolerance and full adherence, intensification of oral LLT could achieve an LDL-C level of less than 70 mg/dL in most patients, with only a modest percentage requiring a PCSK9 inhibitor.
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Affiliation(s)
- Christopher P Cannon
- Baim Institute for Clinical Research, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Irfan Khan
- Global Health Economics and Outcomes Research, Sanofi, Bridgewater, New Jersey
| | | | - Matthew R Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts.,Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Robert J Sanchez
- Medical Affairs, Regeneron Pharmaceuticals, Inc, Tarrytown, New York
| | - William J Sasiela
- Program Direction, Cardiovascular and Metabolism, Regeneron Pharmaceuticals, Inc, Tarrytown, New York
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18
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Taylor BA, Sanchez RJ, Jacobson TA, Chibedi-De-Roche D, Manvelian G, Baccara-Dinet MT, Khan I, Rosenson RS. Application of the Statin-Associated Muscle Symptoms-Clinical Index to a Randomized Trial on Statin Myopathy. J Am Coll Cardiol 2019; 70:1680-1681. [PMID: 28935043 DOI: 10.1016/j.jacc.2017.07.767] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022]
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19
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Cannon CP, Sanchez RJ, Klimchak AC, Khan I, Sasiela WJ, Reynolds MR, Rosenson RS. Simulation of the Impact of Statin Intolerance on the Need for Ezetimibe and/or Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor for Meeting Low-Density Lipoprotein Cholesterol Goals in a Population With Atherosclerotic Cardiovascular Disease. Am J Cardiol 2019; 123:1202-1207. [PMID: 30736965 DOI: 10.1016/j.amjcard.2019.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 12/23/2022]
Abstract
In a population with atherosclerotic cardiovascular disease, previous research indicated that approximately 86% can achieve low-density lipoprotein cholesterol (LDL-C) of <70 mg/dL with oral lipid-lowering therapies (LLT) only, whereas 14% would require a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. We aim to estimate these values accounting for varying levels of statin intolerance. A simulation model described previously was used to estimate the utilization of LLT needed to achieve LDL-C <70 mg/dL via an intensification algorithm which maximized statins before adding ezetimibe or a PCSK9 inhibitor. The current analysis took into account varying background rates of statin intolerance. We defined statin intolerance as either partial (inability to tolerate high-intensity statin) or full (inability to tolerate any statin). With treatment intensification and 10% of patients having partial statin intolerance, the use of ezetimibe (± statin ± PCSK9 inhibitor) increased from 32.7% to 34.9%, and the need for a PCSK9 inhibitor (+ ezetimibe ± statin) increased from 14.0% to 15.5%. If, instead, 10% were fully statin intolerant, the use of ezetimibe (± statin ± PCSK9 inhibitor) increased from 32.7% to 38.5%, and the use of a PCSK9 inhibitor (+ ezetimibe ± statin) increased from 14.0% to 19.7%. In conclusion, in our simulation-based study, partial statin intolerance increased the need for nonstatins only modestly (by an absolute 2.2%), whereas having 10% of patients with full statin intolerance increased the need for PCSK9 inhibitors from 14% overall to approximately 20%.
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Affiliation(s)
- Christopher P Cannon
- Brigham and Women's Hospital, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
| | | | | | | | | | - Matthew R Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts; Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Robert S Rosenson
- Department of Medicine, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
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20
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Navar AM, Wojdyla DM, Sanchez RJ, Steen DL, Khan I, Peterson ED, Pencina MJ. P291Predicting recurrent CVD events among adults with stable CVD: a new risk model based on pooled NIH cohorts. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A M Navar
- Duke Clinical Research Institute, Durham, United States of America
| | - D M Wojdyla
- Duke Clinical Research Institute, Durham, United States of America
| | - R J Sanchez
- Regeneron Pharmaceuticals, Tarrytown, New York, United States of America
| | - D L Steen
- University of Cincinnati, Cincinnati, United States of America
| | - I Khan
- Sanofi, Bridgewater, New Jersey, United States of America
| | - E D Peterson
- Duke Clinical Research Institute, Durham, United States of America
| | - M J Pencina
- Duke Clinical Research Institute, Durham, United States of America
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Lin I, Sung J, Sanchez RJ, Mallya UG, Friedman M, Panaccio M, Koren A, Neumann P, Menzin J. Patterns of Statin Use in a Real-World Population of Patients at High Cardiovascular Risk. J Manag Care Spec Pharm 2017; 22:685-98. [PMID: 27231796 PMCID: PMC10397919 DOI: 10.18553/jmcp.2016.22.6.685] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Widespread use of statins has improved hypercholesterolemia management, yet a significant proportion of patients remain at risk for cardiovascular (CV) events. Analyses of treatment patterns reveal inadequate intensity and duration of statin therapy among patients with hypercholesterolemia, and little is known about real-world statin use, specifically in subgroups of patients at high risk for CV events. OBJECTIVE To examine patterns of statin use and outcomes among patients with high-risk features who newly initiated statin monotherapy. METHODS Adult patients (aged > 18 years) at high CV risk who received > 1 prescription for statin monotherapy and who had not received lipid-modifying therapy during the previous 12 months were identified from the Truven MarketScan Commercial and Medicare Supplemental databases (from January 2007 to June 2013). Patients with atherosclerotic cardiovascular disease (ASCVD) or diabetes were hierarchically classified into 5 mutually exclusive CV risk categories (listed here in order from highest to lowest risk): (1) recent CV event (subcategorized by hospitalization for acute coronary syndrome [ACS] or other non-ACS CV event within 90 days of index); (2) coronary heart disease (CHD); (3) history of ischemic stroke; (4) peripheral artery disease (PAD); and (5) diabetes. Outcomes of interest included changes in therapy, proportion of days covered (PDC), time to discontinuation, and proportion of patients with ASCVD-related inpatient visit during the follow-up period. Statin therapy was subdivided into high-intensity treatment (atorvastatin 40 mg or 80 mg, rosuvastatin 20 mg or 40 mg, or simvastatin 80 mg) or moderate- to low-intensity treatment (all other statins and statin dosing regimens). Follow-up data were obtained from the index date (statin initiation) until the end of continuous enrollment. RESULTS A total of 541,221 patients were included in the analysis. The majority of patients were stratified in the diabetes cohort (61.1%), followed in frequency by recent ACS event (15.8%), recent non-ACS CV event (9.9%), PAD (4.7%), CHD (4.4%), and history of ischemic stroke (4.1%). Only 15.0% of the population initiated therapy with a high-intensity statin, and 22.5% of these high-intensity statin initiators switched to a moderate- to low-intensity regimen during the follow-up period. Median time to statin discontinuation was approximately 15 months. Duration of treatment was longer among those who were treated with a high-intensity versus a moderate- to low-intensity statin regimen (21 and 15 months, respectively). The PDC was highest in the recent ACS hospitalization cohort (66.4%) and lowest in the diabetes cohort (55.5%). The PDC was significantly greater among patients who initiated treatment with a high-intensity statin regimen than with a moderate- to low-intensity statin regimen (62.1% vs. 57.5%, respectively; P< 0.001). At 1 year, Kaplan-Meier estimates of the cumulative rates for ASCVD-related hospitalizations ranged from 3.5% (diabetes) to 21.8% (recent ACS hospitalization). CONCLUSIONS Patients at high risk for CV events are suboptimally dosed with statins, have high rates of discontinuation, and have low rates of adherence. Despite the use of statin therapy, ASCVD-related inpatient visit rates were high, particularly among those patients at highest risk because of a recent ACS hospitalization. Future interventions are required to ensure that high-risk patients are effectively managed to reduce subsequent morbidity and mortality. DISCLOSURES Support for this research was provided by Regeneron Pharmaceuticals, Tarrytown, New York, and Sanofi US, Bridgewater, New Jersey. Menzin and Lin are employees of Boston Health Economics, which received consulting fees from Sanofi. Friedman is a consultant to Boston Health Economics. Lin, Friedman, and Menzin have received research support from Sanofi US. Sung, Mallya, Panaccio, and Koren are employees of Sanofi US and also have ownership interest in Sanofi US. Sanchez is an employee of and has ownership interest in Regeneron Pharmaceuticals. Neumann has served on advisory boards for Merck & Co, Takeda Pharmaceutical Company, Genentech, Novartis, Bayer AG, UCB, Sanofi US, Robert Wood Johnson Foundation, and Cubist and serves as consultant for Boston Health Economics, Forrest, P urdue, and Smith and Nephew. This research has been presented in part at the International Society for Pharmacoeconomics and Outcomes Research, 20th Annual International Meeting, May 16-20, 2015, Philadelphia, Pennsylvania. All authors contributed to the study design, protocol development, and results interpretation. Lin and Menzin were responsible for conducting the study analyses. All authors were involved in manuscript development and approved the submitted version.
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Affiliation(s)
- Iris Lin
- 1 Boston Health Economics, Waltham, Massachusetts
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Kuiper JG, Sanchez RJ, Houben E, Heintjes EM, Penning-van Beest FJ, Khan I, van Riemsdijk M, Herings RM. Use of Lipid-modifying Therapy and LDL-C Goal Attainment in a High-Cardiovascular-Risk Population in the Netherlands. Clin Ther 2017; 39:819-827.e1. [DOI: 10.1016/j.clinthera.2017.03.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/23/2017] [Accepted: 03/01/2017] [Indexed: 12/27/2022]
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Steen DL, Khan I, Ansell D, Sanchez RJ, Ray KK. Retrospective examination of lipid-lowering treatment patterns in a real-world high-risk cohort in the UK in 2014: comparison with the National Institute for Health and Care Excellence (NICE) 2014 lipid modification guidelines. BMJ Open 2017; 7:e013255. [PMID: 28213597 PMCID: PMC5318572 DOI: 10.1136/bmjopen-2016-013255] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND In 2014, guidelines from the National Institute for Health and Care Excellence (NICE) provided updated recommendations on lipid-modifying therapy (LMT). We assessed clinical practice contemporaneous to release of these guidelines in a UK general practice setting for secondary and high-risk primary-prevention populations, and extrapolated the findings to UK nation level. METHODS Patients from The Health Improvement Network database with the following criteria were included: lipid profile in 2014 (index date); ≥20 years of age; ≥2 years representation in database prior to index; ≥1 statin indication either for atherosclerotic cardiovascular disease (ASCVD) or the non-ASCVD conditions high-risk diabetes mellitus and/or chronic kidney disease. RESULTS Overall, 183 565 patients met the inclusion criteria (n=91 479 for ASCVD, 92 086 for non-ASCVD). In those with ASCVD, 79% received statin treatment and 31% received high-intensity statin. In the non-ASCVD group, 62% were on a statin and 57% received medium-intensity or high-intensity statin. In the ASCVD and non-ASCVD cohorts, 6% and 15%, respectively, were already treated according to dosing recommendations as per updated NICE guidelines. Extrapolation to the 2014 UK population indicated that, of the 3.3 million individuals with ASCVD, 2.4 million would require statin uptitration and 680 000 would require statin initiation (31% de novo initiation, 60% reinitiation, 9% addition to non-statin LMT) to achieve full concordance with updated guidelines. Of the 3.5 million high-risk non-ASCVD individuals, 1.6 million would require statin uptitration and 1.4 million would require statin initiation (59% de novo initiation, 36% reinitiation, 5% addition to non-statin LMT). CONCLUSIONS A large proportion of UK individuals with ASCVD and high-risk non-ASCVD received statin treatment (79% and 62%, respectively) during the year of NICE 2014 guidelines release. Up to 94% of patients with ASCVD and 85% of high-risk non-ASCVD individuals, representing ∼3 million individuals in each group, would require statin uptitration or initiation to achieve full concordance with updated guidelines.
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Affiliation(s)
- Dylan L Steen
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Irfan Khan
- Global Health Economics and Outcomes Research, Sanofi, Bridgewater, New Jersey, USA
| | | | - Robert J Sanchez
- Global Health Economics and Outcomes Research, Regeneron Pharmaceuticals Inc., Tarrytown, New York, USA
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College, London, UK
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Steen DL, Khan I, Becker L, Foody JM, Gorcyca K, Sanchez RJ, Giugliano RP. Patterns and predictors of lipid-lowering therapy in patients with atherosclerotic cardiovascular disease and/or diabetes mellitus in 2014: Insights from a large US managed-care population. Clin Cardiol 2016; 40:155-162. [PMID: 28026031 DOI: 10.1002/clc.22641] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/29/2016] [Accepted: 10/09/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Lowering low-density lipoprotein cholesterol with statins reduces risk of cardiovascular events. We examined patterns and predictors of filled prescriptions for lipid-lowering therapy (LLT) in subgroups of patients with atherosclerotic cardiovascular disease (ASCVD) and/or diabetes mellitus (DM). HYPOTHESIS Statin treatment remains underutilized across subgroups of high CV risk patients. METHODS Patients in the Optum Research Database with these criteria were included: age ≥20 years, 2 years continuous enrollment, and ASCVD and/or DM. Patients were hierarchically classified by the presence of recent acute coronary syndrome, other coronary heart disease, ischemic stroke, peripheral arterial disease (PAD), or only DM. Predictors of filled LLT regimens were examined using multinomial logistic regression. RESULTS A total of 1 055 932 individuals met all inclusion criteria. Evidence by point-in-time analysis of filled (not only written) statin prescriptions was 45% for the overall cohort. By subgroups, this was 62%, 52%, 43%, 36%, and 40% for recent acute coronary syndrome, other coronary heart disease, ischemic stroke, PAD, and only DM, respectively. Predictors of higher rates of any statin regimen included age 50 to 69 years, male sex, absence of comorbidities, and filled prescriptions of other standard-of-care therapies. CONCLUSIONS In 2014, only 49% of patients with ASCVD and 40% with only DM had evidence for a filled statin prescription. Those with indications of ischemic stroke, PAD, and DM were less likely to receive statins than those with coronary conditions. Other characteristics such as advanced age, female sex, and noncardiac conditions predicted less statin utilization, thereby representing good targets for quality improvement.
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Affiliation(s)
- Dylan L Steen
- Division of Cardiovascular Health and Disease, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Irfan Khan
- Global Health Economics and Outcomes Research, Sanofi, Bridgewater, New Jersey
| | - Laura Becker
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota
| | - JoAnne M Foody
- Formerly of: Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine Gorcyca
- Global Health Economics and Outcomes Research, Sanofi, Bridgewater, New Jersey
| | - Robert J Sanchez
- Health Economics and Outcomes Research, Regeneron Pharmaceuticals Inc., Tarrytown, New York
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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Navar AM, Peterson ED, Wojdyla D, Sanchez RJ, Sniderman AD, D’Agostino RB, Pencina MJ. Temporal Changes in the Association Between Modifiable Risk Factors and Coronary Heart Disease Incidence. JAMA 2016; 316:2041-2043. [PMID: 27838711 PMCID: PMC5547567 DOI: 10.1001/jama.2016.13614] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ann Marie Navar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Allan D. Sniderman
- Mike Rosenbloom Laboratory for Cardiovascular Research, McGill University Health Centre, Montreal, Canada
| | - Ralph B. D’Agostino
- Department of Mathematics and Statistics, Boston University, Boston, MA, USA
| | - Michael J. Pencina
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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Huang Q, Grabner M, Sanchez RJ, Willey VJ, Cziraky MJ, Palli SR, Power TP. Clinical Characteristics and Unmet Need Among Patients with Atherosclerotic Cardiovascular Disease Stratified by Statin Use. Am Health Drug Benefits 2016; 9:434-444. [PMID: 28465771 PMCID: PMC5394554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/14/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND The American College of Cardiology (ACC)/American Heart Association (AHA) 2013 guidelines for blood cholesterol treatment recommend high-intensity statins for adults with atherosclerotic cardiovascular disease (ASCVD). Currently, little is known about the real-world patient characteristics of ASCVD, as well as the clinical and economic consequences of different treatment options for this disease. OBJECTIVES To compare the demographic, clinical, and economic characteristics of patients with clinical ASCVD who started therapy with high-intensity statins, low-/moderate-intensity statins, or no statins in usual-care settings based on data primarily before the release of the ACC/AHA 2013 guidelines. METHODS This retrospective, observational cohort study used claims data from US commercial health plans from January 2006 to June 2014 to identify patients with ASCVD (ie, acute coronary syndrome, coronary heart disease, ischemic stroke, or peripheral arterial disease). High-intensity, low-/moderate-intensity statin users and non-statin users were selected based on the presence of a corresponding prescription fill. The index date was defined as the first statin fill date for the statin cohorts and the earliest eligibility date for clinical ASCVD for the non-statin users group. The follow-up outcomes, including treatment patterns, cardiovascular (CV) events, and healthcare utilization and costs, were assessed after matching the high-intensity statin and low-/moderate-intensity statin initiators. RESULTS A total of 273,308 patients with ASCVD were included in the study; of these, 104,649 were statin initiators and 168,659 non-statin users. Only 8.8% (N = 24,106) of the total population initiated high-intensity statins. Patient adherence (defined as proportion of days covered ≥80%) to statin therapy was low in the matched high-intensity statin and low-/moderate-intensity statin cohorts (27.0% vs 26.4%, respectively). Approximately 16% of the patients in either of the matched cohorts had at least 1 CV event during the available follow-up period. CONCLUSION The low percentage of patients who initiated high-intensity statin therapy, low adherence to statin therapy, and high rates of CV events during the follow-up period suggest a substantial unmet need among patients with ASCVD in the real-world setting. The demographic and clinical heterogeneity across the cohorts suggests significant variability in physician perception of the appropriate use of statins and may provide an opportunity to improve care and health outcomes in these high-risk patients.
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Affiliation(s)
- Qing Huang
- Research Manager of Life Sciences Research, HealthCore, Wilmington, DE
| | | | - Robert J Sanchez
- Senior Director of Health Economics and Outcomes Research, Medical Affairs, Regeneron Pharmaceuticals, Tarrytown, NY
| | | | | | - Swetha R Palli
- Research Manager of Life Sciences Research, HealthCore, during this study
| | - Thomas P Power
- Medical Director of Cardiology and Sleep Management, AIM Specialty Health, Chicago, IL
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Graham JH, Sanchez RJ, Saseen JJ, Mallya UG, Panaccio MP, Evans MA. Clinical and economic consequences of statin intolerance in the United States: Results from an integrated health system. J Clin Lipidol 2016; 11:70-79.e1. [PMID: 28391913 DOI: 10.1016/j.jacl.2016.10.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although statins are considered safe and effective, they have been associated with statin intolerance (SI) in clinical and observational studies. OBJECTIVE The objective of this study was to describe the clinical and economic consequences of SI through comparison of an SI cohort of patients with matched controls. METHODS This study used data extracted from an integrated health system's electronic health records from 2008 to 2014. Adults with SI were matched to controls using a propensity score. Patients were hierarchically classified into 6 mutually exclusive cardiovascular (CV)-risk categories: recent acute coronary syndrome (ACS; ≤12 months preindex), coronary heart disease, ischemic stroke, peripheral artery disease, diabetes, or primary prevention. The study endpoints, low-density lipoprotein cholesterol (LDL-C) goal attainment, medical costs, and time to first CV event were compared using conditional logistic regression, generalized linear, and Cox proportional hazards models, respectively. RESULTS Patients with SI (n = 5190) were matched with controls (n = 15,570). Patients with SI incurred higher medical costs and were less likely to reach LDL-C goals than controls. Patients with SI were at higher risk for revascularization procedures in all CV risk categories except ACS, and those in the diabetes risk category were at higher risk for any CV event. There was a lower risk of all-cause death among patients with SI. CONCLUSIONS Patients with SI were less likely to reach LDL-C goals, incurred higher health care costs, and experienced a higher risk for nonfatal CV events than patients without SI. Alternative management strategies are needed to better treat high CV risk patients.
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Affiliation(s)
| | | | - Joseph J Saseen
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Teramoto T, Uno K, Miyoshi I, Khan I, Gorcyca K, Sanchez RJ, Yoshida S, Mawatari K, Masaki T, Arai H, Yamashita S. Low-density lipoprotein cholesterol levels and lipid-modifying therapy prescription patterns in the real world: An analysis of more than 33,000 high cardiovascular risk patients in Japan. Atherosclerosis 2016; 251:248-254. [DOI: 10.1016/j.atherosclerosis.2016.07.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/15/2023]
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Tatlock S, Grant L, Spertus JA, Khan I, Arbuckle R, Manvelian G, Sanchez RJ. Development and Content Validity Testing of a Patient-Reported Treatment Acceptance Measure for Use in Patients Receiving Treatment via Subcutaneous Injection. Value Health 2015; 18:1000-1007. [PMID: 26686784 DOI: 10.1016/j.jval.2015.09.2937] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/07/2015] [Accepted: 09/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND New therapies in development for lowering low-density lipoprotein cholesterol, such as alirocumab, require administration by subcutaneous injections. There is a need to assess the acceptance of such treatments and their mode of administration. OBJECTIVES To develop a novel patient-reported outcome measure, the Injection-Treatment Acceptance Questionnaire (I-TAQ), and assess its content validity using qualitative methods. METHODS Concepts generated from a literature and instrument review informed the initial drafting of 17 items in the I-TAQ, with item wording adapted from three existing instruments. Three rounds of qualitative interviews were conducted with 29 US-English speaking patients at high cardiovascular risk. Concept elicitation questioning was used to explore patients' treatment experiences followed by cognitive debriefing of the I-TAQ using "think-aloud" methods. Verbatim transcripts were analyzed using thematic analysis. RESULTS Qualitative analysis of concept elicitation data identified the following relevant concepts: perceived efficacy, side effects, self-efficacy, convenience, and overall acceptance. Seven (24%) patients discussed an initial fear of needles, but described this as subsiding with no impact on adherence. Five items were added after round one interviews, three of which were retained after round two testing in which two further items were added, forming the conceptually comprehensive 22-item I-TAQ. Patients demonstrated good understanding of item wording, instructions, response scales, and recall period. CONCLUSIONS Successive rounds of in-depth interviews resulted in a treatment acceptance measure with strong content validity. Pending demonstration of its psychometric properties, the I-TAQ may prove to be a valuable measure of patients' perspectives toward being treated with low-density lipoprotein cholesterol-lowering therapies requiring subcutaneous injections.
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Affiliation(s)
- Sophi Tatlock
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK.
| | - Laura Grant
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK
| | - John A Spertus
- Mid America Heart Institute of Saint Luke's Hospital and the University of Missouri - Kansas City, Kansas City, MO, USA
| | | | - Rob Arbuckle
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, UK
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Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits 2015; 8:384-94. [PMID: 26557232 PMCID: PMC4636277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 06/26/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Given the dramatic increase in total knee and hip replacement procedures among the US population aged 45 years and older, there is a need to compare the downstream healthcare utilization and costs between patients who undergo joint replacement and those who receive intraarticular injections as a low-cost alternative. OBJECTIVE To compare changes in osteoarthritis (OA)-related healthcare utilization and costs for Medicare members with OA who underwent knee or hip replacement versus those receiving steroid or viscosupplementation injections. METHODS Medicare members aged ≥45 years diagnosed with OA were identified for this retrospective longitudinal study. Data were compared for patients who underwent primary knee or hip replacement surgery between July 1, 2007, and June 30, 2012, and those receiving injection of pain-relief medication during the same period. The date of joint replacement surgery was considered the index date. For the comparison cohort, the index date was 180 days postinjection of the first intraarticular injection. Medical and pharmacy claims were examined longitudinally in 90-day increments, from 180 days preindex until 360 days postindex. Difference-in-difference analyses were conducted to compare the change in OA-related healthcare costs, postindex versus preindex, between the study cohorts. Time-to-event analyses were used to measure rates of readmissions and venous thromboembolism (VTE). RESULTS The mean age was 70.7 years for patients with knee replacement, 71.7 years for those with hip replacement, and 71.1 years for those receiving pain-relief injection (P <.0001). The RxRisk-V comorbidity index scores were 4.7, 4.4, and 4.8, respectively (P <.0001). Difference-in-difference analyses indicated that decreases in OA-related costs were greater for the joint replacement cohorts (coefficient for knee replacement*time: -0.603; hip replacement*time: -0.438; P <.001 for both) than for the comparison cohort. The VTE rates were 5.6% (knee) and 5.1% (hip) postsurgery versus 1.4% (knee) and 1.3% (hip) presurgery. CONCLUSION The overall difference-in-difference results showed a greater decrease in healthcare utilization and costs for the members with joint replacement than for those receiving injection.
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Affiliation(s)
- Margaret K Pasquale
- Dr Pasquale is Research Manager, Comprehensive Health Insights, Humana, Louisville, KY
| | - Anthony M Louder
- Dr Louder is Principal Researcher, Comprehensive Health Insights, Humana, Louisville, KY
| | - Raymond Y Cheung
- Dr Cheung is Clinical Director, Pain Therapeutic Area Sub-Team, Pfizer Clinical Sciences, Pfizer, New York, NY
| | - Andrew T Reiners
- Dr Reiners is Medical Director, Commercial Clinical Review, Health Guidance Organization, Humana, Louisville, KY
| | - Jack Mardekian
- Dr Mardekian is Senior Statistician, Global Innovative Pharma, Pfizer, New York, NY
| | - Robert J Sanchez
- Dr Sanchez was Senior Director, Health Economics and Outcomes Research, Pfizer, New York, NY
| | - Veerainder Goli
- Dr Goli is Vice President, Clinical Disease Expert Area - Pain, Global Innovative Pharma, Pfizer, Durham, NC, and Professor Emeritus, Duke University Medical Center, Durham, NC
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Abstract
BACKGROUND The purpose of this study was to determine if primary care patients with low back pain (LBP) cluster into definable care utilization subgroups that can be explained by patient and provider characteristics. MATERIALS AND METHODS Adult primary care patients with an incident LBP encounter were identified from Geisinger Clinic electronic health records over 5 years. Two-thirds of the cohort had only one to two encounters. Principal component analysis was applied to the data from the remaining one-third on use of ambulatory, inpatient, emergency department, and surgery care and use of magnetic resonance imaging, injections, and opioids in 12 months following the incident encounter. Groups were compared on demographics, health behaviors, chronic and symptomatic disease burden, and a measure of physician efficiency. RESULTS Six factors with eigenvalues >1.5 explained 71% of the utilization variance. Patient subgroups were defined as: 1-2 LBP encounters; 2+ surgeries; one surgery; specialty care without primary care; 3+ opioid prescriptions; laboratory dominant care; and others. The surgery and 3+ opioid subgroups, while accounting for only 10.4% of the cohort, had used disproportionately more magnetic resonance imaging, emergency department, inpatient, and injectable resources. The specialty care subgroup was characterized by heavy use of inpatient care and the lowest use of injectables. Anxiety disorder and depression were not more prevalent among the surgery patients than in the others. Surgery patients had features in common with specialty care patients, but were older, had higher prevalence of Fibromyalgia, and were associated primary care physicians with worse efficiency scores. CONCLUSION LBP care utilization is highly variable and concentrated in small subgroups using disproportionate amounts of potentially avoidable care that reflect both patient and provider characteristics.
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Affiliation(s)
| | - Xiaowei Yan
- Geisinger Center for Health Research, Seattle, WA, USA
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Sanchez RJ, Graham JH, Evans MA, Mallya UG, Panaccio MP, Steinhubl SR. Abstract 146: Clinical and Economic Consequences of Statin Intolerance in the U.S.: Results from an Integrated Health System. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Low-density lipoprotein cholesterol (LDL-C) is a key therapeutic target for reducing risk of cardiovascular (CV) events. While statins are the mainstay of therapy due to efficacy and safety, observational studies indicate patients prescribed statins are unable to tolerate them to varying degrees. The study objective was to examine the clinical and economic consequences of statin intolerance (SI) comparing SI patients to non-SI patients on statin therapy.
Methods:
This retrospective cohort study used data from an integrated health system’s electronic health record from 2009-2014. Adult patients diagnosed as statin intolerant (identified through a custom diagnosis code), with ≥ 6 months pre- and post-index date eligibility were considered for the study. All patients were hierarchically ordered into 6 mutually exclusive CV risk categories: recent acute coronary syndrome (ACS, < 12 months pre-index); coronary heart disease (CHD); ischemic stroke; peripheral artery disease (PAD); diabetes; or primary prevention. Index dates were defined as the SI diagnosis date for SI patients and a matched encounter date within ±90 days for controls. A total of 5,252 SI patients were matched to 15,756 non-SI statin users (1:3 ratio) using a propensity score that included CV risk, Charlson comorbidity index, and other clinical characteristics as covariates. Time to first myocardial infarction, unstable angina, coronary revascularization, ischemic stroke, and CV death were compared between groups using Kaplan-Meier plots and Cox proportional hazard models. Total medical costs and LDL-C goal attainment were compared using generalized linear models and conditional logistic regression, respectively.
Results:
The mean age of the study population was 62 years with the majority being females (61%). Three percent were categorized as recent ACS, followed by 22% for CHD, 1% ischemic stroke, 5% PVD, 17% diabetes and 52% primary prevention patients. Before matching, 5% of statin users were deemed statin intolerant by their provider; although, 86% were still able to tolerate at least asymmetric statin dosing. Compared to the matched cohort, SI patients experienced significantly higher risk of unstable angina (hazard ratio (HR)=1.55, 95% CI=1.29-1.86) and revascularization procedures (HR=1.78, 95% CI=1.47-2.17) but lower risk of CV death (HR 0.42, 95% CI=0.33-0.55). Patients with statin intolerance also experienced higher costs (cost ratio=1.21, 95% CI=1.12, 1.29) and a higher risk of not achieving LDL-C goal (odds ratio=1.84, 95% CI=1.58-2.13). All p-values were <0.0001.
Conclusion:
While the majority of SI patients were on a statin, SI patients demonstrate a higher risk of some cardiovascular events; incur higher healthcare costs; and difficulty reaching LDL-C goals compared to patients without SI. Alternative treatment strategies are needed to better serve this at-risk patient population.
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Shin J, McCombs JS, Sanchez RJ, Udall M, Deminski MC, Cheetham TC. Primary nonadherence to medications in an integrated healthcare setting. Am J Manag Care 2012; 18:426-434. [PMID: 22928758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To measure primary nonadherence (PNA) rates for 10 therapeutic drug groups and identify factors associated with PNA to chronic and acute medications. STUDY DESIGN Retrospective cohort study. METHODS New prescriptions written in an integrated healthcare system for study drugs were identified between December 1, 2009, and February 28, 2010. PNA was defined as the failure to fill a prescription within 14 days of when it was written. PNA rates were calculated by drug group and descriptive statistics were performed. Multivariable logistic regression was used to identify significant patient, provider, and prescription characteristics associated with PNA. Results were stratified by acute versus chronic treatment. RESULTS A total of 569,095 new prescriptions were written during the 3-month period. Across all drug groups, the PNA rate was 9.8%. PNA rates for individual drug groups varied and were highest for osteoporosis medications (22.4%) and antihyperlipidemics (22.3%). Patients who filled at least 1 prescription in the prior year (odds ratio [OR], 95% confidence interval [CI] for acute = 0.06 [0.06-0.07], for chronic = 0.11 [0.10-0.12]) or had a prescription for a symptomatic disease (OR = 0.51 [0.48-0.53]) were more likely to fill their prescription. Patients were more likely to be primary nonadherent if they were black (OR acute = 1.30 [1.25-1.36], chronic = 1.26 [1.18-1.33]) or treatment-naive to therapy (OR acute = 2.52 [2.36-2.7], chronic=1.07 [1.03-1.12]). CONCLUSIONS Overall PNA was 9.8% but individual PNA rates varied by therapeutic drug group. Factors of PNA were mostly consistent across drug groups, but some depended on whether the treatment was acute or chronic.
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Affiliation(s)
- Janet Shin
- Pharmacy Analytical Services Kaiser Permanente Southern California, Downey, CA 90242, USA.
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Sanchez RJ, Mardekian J, Cziraky MJ, Mullins CD. Developing a collaborative study protocol for combining payer-specific data and clinical trials for CER. J Manag Care Pharm 2011; 17:S34-7. [PMID: 22074673 PMCID: PMC10437906 DOI: 10.18553/jmcp.2011.17.s9-a.s34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Jack Mardekian
- Pfizer, Inc., 235 East 42nd Street, New York, NY 10017. USA.
| | - Mark J. Cziraky
- Pfizer, Inc., 235 East 42nd Street, New York, NY 10017. USA.
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Alemayehu D, Sanchez RJ, Cappelleri JC. Considerations on the use of patient-reported outcomes in comparative effectiveness research. J Manag Care Pharm 2011; 17:S27-33. [PMID: 22074672 PMCID: PMC10438265 DOI: 10.18553/jmcp.2011.17.s9-a.s27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mullins CD, Sanchez RJ. It is important to note that RWD will never replace the more traditional and more robust RCT data; however, the emerging trend is to incorporate data that are more generalizable. Introduction. J Manag Care Pharm 2011; 17:S03-S4. [PMID: 22074667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND The Patient Protection and Affordable Care Act brought considerable attention to comparative effectiveness research (CER). OBJECTIVES To (a) suggest best practices for conducting and reporting CER using "real-world data" (RWD), (b) describe some of the data and infrastructure requirements for conducting CER using RWD, (c) identify statistical challenges with the analysis of nonrandomized studies and suggest appropriate techniques to address those challenges, (d) recognize the value of patient-reported outcomes in CER, (e) encourage the incorporation of observational data into randomized controlled studies, and (f) highlight the importance of incorporating payers in industry-sponsored research. SUMMARY The first article in this supplement, "Something old, something new…" provides a policy perspective on the recent evolution of CER. It reviews the historical context, discusses the "promise and fear" of CER, and then describes the new role of the Patient-Centered Outcomes Research Institute (PCORI) in defining and sponsoring CER. The second paper, "Ten Commandments," proposes a series of tenets for planning, conducting, and reporting CER done with RWD. Oriented for basic-to-intermediate researchers, it combines standard scientific research principles with considerations specific to nonrandomized, RWD studies. The third article, "Infrastructure Requirements," points out that effective use of secondary data requires addressing major methodological and infrastructural issues, including development of analytical tools to readily access and analyze data, formulation of guidelines to enhance quality and transparency, establishment of data standards, and creation of data warehouses that respect the privacy and confidentiality of patients. It identifies gaps that must be filled to address the underlying issues, with emphasis on data standards, data quality assurance, data warehouses, computing environment, and protection of privacy and confidentiality. The fourth paper, "Statistical Issues," discusses how the validity of analytic results from observational studies is adversely impacted by biases that may be introduced due to lack of randomization. It reviews some of the methodological challenges that arise in the analysis of data from nonrandomized studies, with particular emphasis on the limitations of traditional approaches and potential solutions from recent methodological developments. The fifth paper, "Considerations on the Use of Patient Reported Outcomes (PROs)," describes how PRO data can play a critical role in guiding patients, health care providers, payers, and policy makers in making informed decisions regarding patient-centered treatment from among alternative options and technologies and have been noted as such by PCORI. However, collection and interpretation of such data within the context of CER have not yet been fully established. It discusses some challenges with including PROs in CER initiatives, provides a framework for their effective use, and proposes several areas for future research. Lastly, "Developing a Collaborative Study Protocol…" indicates that there is the potential, the desire, and the capability for payers to be involved in CER studies, combining elements of their own observational data with prospective studies. It describes a case example of a payer, a pharmaceutical company, and a research organization collaborating on a prospective study to examine the effect of prior authorization for pregabalin on health care costs to the payer. CONCLUSION Researchers at Pfizer routinely conduct CER-type studies. In this supplement, we have proposed some approaches that we believe are useful in developing certain kinds of evidence and have described some of our experiences. Our experiences also make us acutely aware of the limitations of approaches and data sources that have been used for CER studies and suggest that there is a need to further develop methods that are most useful for answering CER questions.
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Affiliation(s)
- C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, 220 Arch St, 12th Floor, Baltimore, MD 21201, USA.
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Burke JP, Sanchez RJ, Joshi AV, Cappelleri JC, Kulakodlu M, Halpern R. Health Care Costs in Patients with Painful Diabetic Peripheral Neuropathy Prescribed Pregabalin or Duloxetine. Pain Pract 2011; 12:209-18. [DOI: 10.1111/j.1533-2500.2011.00478.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Burke JP, Sanchez RJ, Joshi AV, Cappelleri JC, Kulakodlu M, Halpern R. Health Care Costs in Patients with Fibromyalgia on Pregabalin vs. Duloxetine. Pain Pract 2011; 12:14-22. [DOI: 10.1111/j.1533-2500.2011.00470.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kleinman NL, Sanchez RJ, Lynch WD, Cappelleri JC, Beren IA, Joshi AV. Health outcomes and costs among employees with fibromyalgia treated with pregabalin vs. standard of care. Pain Pract 2011; 11:540-51. [PMID: 21392253 DOI: 10.1111/j.1533-2500.2011.00453.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare comorbidities, drug use, benefit costs, absences, medication persistence/adherence between employees with fibromyalgia initiating treatment with pregabalin (PGB) vs. antidepressant Standard of Care ([SOC] amitriptyline, duloxetine, or venlafaxine). METHODS Retrospective study of 240 adults initiating PGB or SOC after 7/1/2007. Multivariate regression models on propensity-score-matched cohorts compared postindex costs, absences, and adherence between cohorts. RESULTS Pregabalin users had significantly more preindex muscle pain and dizziness and less depression than SOC (each P < 0.05). Use of some non-PBG/SOC drugs differed. No differences were found in total medical, drug, or absenteeism cost. PGB had more sick leave (9.8 vs. 6.8 days, P = 0.04), but other absence types were similar. All adherence metrics were nonsignificantly greater for PGB vs. SOC. CONCLUSION Despite several comorbidity and drug use differences, most employee benefit outcomes and adherence did not differ between the cohorts.
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Sanchez RJ, Uribe C, Li H, Alvir J, Deminski M, Chandran A, Palacio A. Longitudinal evaluation of health care utilization and costs during the first three years after a new diagnosis of fibromyalgia. Curr Med Res Opin 2011; 27:663-71. [PMID: 21241205 DOI: 10.1185/03007995.2010.550605] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate health care resource utilization and costs 1 year before and 3 years after a fibromyalgia (FM) diagnosis. METHODS This retrospective cohort analysis used claims from Humana to identify newly diagnosed FM patients ≥18 years of age based on ≥2 medical claims for ICD-9 CM code 729.1 and 729.0 between June 1, 2002 and March 1, 2005. Prevalence of comorbidities, as well as utilization and costs of pharmacotherapy and health care services were examined for 12 months preceding (pre-diagnosis) and 36 months following (post-diagnosis) the date of first FM diagnosis. These periods were subdivided into 6-month blocks to better observe patterns of change. RESULTS We identified 2613 FM patients who had a mean age at diagnosis of 58.5 ± 15.3 years and a mean Charlson Comorbidity Index of 0.48 ± 1.05. Of those, 73% were female. The use and costs of pain-related medications rose from pre-diagnosis and remained stable after the 6-month post-diagnosis period, while the use of non-pain-related medications steadily rose from pre-diagnosis to 3 years post-diagnosis. This increase was concomitant with an increase in the presence of conditions that may account for higher resource utilization. The use of recommended FM therapies (i.e., antidepressants and anticonvulsants) increased post-diagnosis but remained less common than other pain-related therapies. Total resource utilization and costs increased during the period up to 6 months after diagnosis. This increase was followed by a decline (7-12 months post-diagnosis), and plateau, with an increase during the final 6 months of the study period. Total mean per patient costs were $3481 for the 6-month post-diagnosis period, and $3588 for the final 6 months. Limitations include potential errors in coding and recording, and an inability of claims analyses to determine causality between resource utilization and the specific diagnosis of interest. CONCLUSIONS An FM diagnosis was associated with increased utilization and pain-related medication cost up to the first 6 months post-diagnosis followed by stabilization over 3 years post-diagnosis. Less use of recommended therapies relative to other therapies suggests that further dissemination of treatment guidelines is needed. An increase in non-pain medications over the observation period accounted for the majority of pharmacy costs. These pharmacy costs may be related to an increasing prevalence of comorbid conditions.
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Louder AM, Joshi AV, Ball AT, Cappelleri JC, Deminski MC, Sanchez RJ. Impact of Celecoxib restrictions in medicare beneficiaries with arthritis. Am J Manag Care 2011; 17:503-512. [PMID: 21819170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To compare the incidence of serious gastrointestinal (GI) complications and associated medical costs in a population with either osteoarthritis (OA) or rheumatoid arthritis (RA) enrolled in Medicare plans with celecoxib formulary restrictions versus plans without such restrictions. METHODS This study was a retrospective cohort analysis of Medicare members in plans with and without celecoxib restrictions. Members diagnosed with OA or RA were identified and followed for 1 year. RESULTS The restricted group had higher levels of nonselective nonsteroidal anti-inflammatory drug use (51% vs 40%, p <.001), and celecoxib use was double in the unrestricted group (16% vs 8%, p <.001). The incidence of a serious GI complication was slightly higher in the restricted group (5.4% vs 4.6%, P <.001). The adjusted mean serious GI complication-related cost for the restricted group was more than 15 times higher than that for the nonrestricted group ($1559 [95% confidence interval (CI) $1341-$1811] vs $101 [95% CI $87-$117]), adjusted mean arthritis-related medical costs were $5733 per year (95% CI $5097-$6448) for the restricted group and $3170 (95% CI $2816-$3569) for the unrestricted group. CONCLUSIONS The restricted group had significantly less use of celecoxib, indicating that restriction was effective at reducing celecoxib utilization. Although limitations exist when comparing populations from different health plans, and the underlying causes of serious GI complications are multifactorial, the restricted group had a higher incidence of serious GI complications and higher costs related to serious GI complications and arthritis.
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Harnett J, Margolis J, Cao Z, Fowler R, Sanchez RJ, Mardekian J, Silverman SL. Real-world evaluation of health-care resource utilization and costs in employees with fibromyalgia treated with pregabalin or duloxetine. Pain Pract 2010; 11:217-29. [PMID: 21199319 DOI: 10.1111/j.1533-2500.2010.00440.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate changes in health-care resource use and costs after initiating pregabalin or duloxetine in employees with fibromyalgia (FM). METHODS Employees (18 to 64 years old) with at least one claim for an FM-attributable medication within 60 days following an FM diagnosis were identified using the Thomson Reuters MarketScan(®) Commercial Database (2006 to 2008). Patients newly initiated on pregabalin were propensity score matched to patients newly initiated on duloxetine. These treatment cohorts were evaluated for changes between the 6-month pre- and post-initiation periods in health-care utilization including prescriptions, imputed medically related work loss and expenditures. Pre- to post-initiation changes were compared between pregabalin and duloxetine using a difference-in-difference approach based on univariate statistics and multivariable models. RESULTS A total of 731 employees with FM initiated on pregabalin (89.9% female, mean age 47.1±9.7 years) were matched with 731 employees initiated on duloxetine (89.5% female, mean age 47.1±9.8 years); other demographic and clinical characteristics were also comparable between cohorts. The adjusted marginal effects were not statistically significant for pre- to post-changes in opioid utilization (P=0.856), number of FM-attributable (P=0.151) or FM-related medications (P=0.462), and all-cause (P=0.323) or FM-attributable (P=0.991) expenditures. Pregabalin was associated with a significantly lower probability of any medically related work loss of 3.2 percentage points (P=0.030) compared with duloxetine, but changes in indirect costs were not significantly different (P=0.600). CONCLUSIONS The changes in health resource utilization and costs after initiation of pregabalin were not significantly different than the changes observed after initiation of duloxetine. These results not only demonstrate an overall similarity of resource utilization, but also suggest cost neutrality between pregabalin and duloxetine.
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Affiliation(s)
- James Harnett
- U.S. Health Economics and Outcomes Research, Global Market Access, Primary Care Business Unit, Pfizer, Inc., New York, New York 10017, USA.
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Ball AT, Xu Y, Sanchez RJ, Shelbaya A, Deminski MC, Nau DP. Nonadherence to oral linezolid after hospitalization: A retrospective claims analysis of the incidence and consequence of claim reversals. Clin Ther 2010; 32:2246-55. [DOI: 10.1016/s0149-2918(10)80027-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2010] [Indexed: 11/24/2022]
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Margolis JM, Cao Z, Onukwugha E, Sanchez RJ, Alvir J, Joshi AV, Mullins CD. Healthcare utilization and cost effects of prior authorization for pregabalin in commercial health plans. Am J Manag Care 2010; 16:447-456. [PMID: 20560688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To compare changes in medication use and costs over time for management of painful diabetic peripheral neuropathy (pDPN) or postherpetic neuralgia (PHN) among patients in commercial health plans requiring prior authorization (PA) for pregabalin versus patients in plans without pregabalin PA policies. STUDY DESIGN Retrospective claims data were obtained for 2005 to 2007 from 6 health plans with pregabalin PA and 6 health plans without pregabalin PA. Differences in resource utilization and costs were compared between baseline and 1-year follow-up periods using a pre-post parallel-group design. METHODS Adults diagnosed as having pDPN or PHN with at least 1 claim for pDPN- or PHN-specific pain medication were selected. Pharmacologic therapy, healthcare utilization, and expenditures were analyzed using bivariate statistics and generalized linear models via a difference-in-differences approach comparing cohorts year over year. RESULTS The 2 cohorts included 2084 patients in PA plans and 1320 patients in non-PA plans. Compared with non-PA plans, plans requiring PA experienced a 5.0-percentage point lower increase in patients using pregabalin year over year (P <.001). Utilization in PA plans of other anticonvulsants was 3.7 percentage points higher (P = .03), while nonopioid analgesic use was 5.2 percentage points lower (P = .01). There were no significant differences in opioid, antidepressant, or other pDPN or PHN medication use or pDPNor PHN-related total healthcare costs. CONCLUSION A PA policy for pregabalin was associated with lower pregabalin utilization, but there was no statistically significant effect on pDPN- or PHN-specific medication or healthcare expenditures.
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Margolis J, Cao Z, Fowler R, Harnett J, Sanchez RJ, Mardekian J, Silverman SL. Evaluation of healthcare resource utilization and costs in employees with pain associated with diabetic peripheral neuropathy treated with pregabalin or duloxetine. J Med Econ 2010; 13:738-47. [PMID: 21091395 DOI: 10.3111/13696998.2010.535878] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate changes in healthcare resource use and costs after initiating pregabalin or duloxetine in employees with pain associated with diabetic peripheral neuropathy (pDPN). METHODS Employees (18-64 years old) with a DPN diagnosis and at least one pDPN-related pain medication claim were identified using the MarketScan Commercial Database (2005-2008). Propensity scored matched pregabalin and duloxetine new starts were evaluated in the 6-month pre- and 6-month post-initiation periods. Study outcomes including imputed medically-related work loss, prescription and healthcare utilization, and associated expenditures were analyzed using univariate statistics and multivariate models in a difference-in-difference approach. RESULTS A total of 473 employees in each treatment group were identified. Mean age was 53.6 (SD 7.0) years for pregabalin and 53.5 (SD 7.4) years for duloxetine. There were no pre-index differences between groups. Adjusted marginal effects were not statistically significant for pre-to-post changes in opioid utilization (p = 0.328), number of pDPN-related analgesic medications (p = 0.506), all-cause healthcare costs (p = 0.895), indirect costs (p = 0.324), or pDPN-attributable expenditures (p = 0.359). LIMITATIONS Claims analysis is limited in accounting for all patient and plan differences, and by the reliability of medical claims for diagnosis coding. The sample size of the matched cohorts may have limited the power of the analysis to detect differences. CONCLUSIONS There were no significant pre-to-post differences between pregabalin and duloxetine treatment groups in pDPN-related analgesic medication use, or pDPN-attributable, all-cause, and indirect expenditures.
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Affiliation(s)
- Jay Margolis
- Thomson Reuters, Healthcare & Science, Washington, DC 19004, USA.
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Abstract
OBJECTIVE To examine the prevalence of probable overactive bladder (OAB) in black, Hispanic, and white women. RESEARCH DESIGN AND METHODS This was a cross-sectional survey of women (aged > or = 18 years) presenting to a private obstetrics and gynecology group practice. The survey consisted of the Overactive Bladder-Validated 8 (OAB-V8) and other questions related to ethnicity, health history, desire for treatment, and reason for visit. MAIN OUTCOME MEASURE The OAB-V8 is a validated, eight-item, self-administered questionnaire that assesses the degree of bother associated with OAB symptoms. Subjects scoring > or = 8 on the OAB-V8 were considered to have probable OAB. RESULTS A total of 947 women completed the OAB-V8: 82% were black, 10% were white, and 4% were Hispanic. The prevalence of probable OAB was similar among different races/ethnicities, with 35% of black, 36% of Hispanic, and 30% of white women scoring > or = 8 on the OAB-V8. Micturition frequency, nocturia, and waking up at night were the most bothersome symptoms. History of constipation, history of urinary tract infection, and number of pregnancies were independent risk factors for probable OAB. Thirty-five percent of patients with probable OAB and 5% of those without OAB desired information about OAB treatment options; however, only 5% of patients reported visiting their doctor for reasons related to their bladder symptoms. CONCLUSIONS OAB is prevalent among black, white, and Hispanic women. Using a simple OAB awareness tool, such as the OAB-V8, can help clinicians identify patients with bothersome OAB symptoms who could benefit from treatment. The survey results may have been limited by incorrect self-reported responses, the demographics of the population, and incomplete surveys.
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Chan MR, Bedi S, Sanchez RJ, Young HN, Becker YT, Kellerman PS, Yevzlin AS. Stent placement versus angioplasty improves patency of arteriovenous grafts and blood flow of arteriovenous fistulae. Clin J Am Soc Nephrol 2008; 3:699-705. [PMID: 18256373 DOI: 10.2215/cjn.04831107] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND While endovascular stent placement is the standard of care in most percutaneous coronary and peripheral artery intervention, its role in the salvage of thrombosed and stenotic hemodialysis access remains controversial. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We compared the effects of stent versus angioplasty on primary patency rates in the treatment of stenotic arteriovenous fistulae (AVF) and arteriovenous grafts (AVGs). Moreover, we compared access flow (Qa) and urea reduction ratio (URR) between the two groups as a metric of the effect of stent placement versus angioplasty on dialysis delivery. RESULTS Cox regression analysis revealed that the primary assisted AVG patency was significantly longer for the stent group compared with angioplasty, with a median survival of 138 versus 61 d, respectively (aHR = 0.17; 95% confidence interval, 0.07 to 0.39; P < 0.001). The primary AVG patency for stent versus angioplasty was 91% versus 80% at 30 d, 69% versus 24% at 90 d, and 25% versus 3% at 180 d, respectively. The primary assisted AVF patency did not differ significantly between the stent and angioplasty groups. In patients dialyzing via AVF, multiple regression analysis revealed that stent placement was associated with improved after intervention peak Qa, 1627.50 ml/min versus 911.00 ml/min (beta = 0.494; P = 0.008), change in Qa from before to after intervention, 643.54 ml/min versus 195.35 ml/min (beta = 0.464; P = 0.012), and change in URR from before to after intervention, 5.85% versus 0.733% (beta = 0.389; P = 0.039). CONCLUSIONS Our results suggest that stent placement is associated with improved AVG primary assisted patency and improved AVF blood flow, which may significantly impact on dialysis adequacy.
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Affiliation(s)
- Micah R Chan
- Department of Medicine, Section of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53713, USA.
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Yevzlin AS, Song GU, Sanchez RJ, Becker YT. Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis. J Vasc Access 2007; 8:245-251. [PMID: 18161669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Tunneled cuffed internal jugular vein catheters are widely used to provide short to medium-term vascular access for hemodialysis. The NKF-K/DOQI guidelines state that fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The KDOQI recommendation makes it difficult for Nephrologists to perform this procedure without access to fluoroscopy. This results in unnecessary waiting times and the inappropriate use of acute, non-tunneled catheters. The purpose of this study is: 1) to compare the outcomes of fluoroscopically guided vs modified traditional catheter placement technique, and 2) to perform a cost analysis of the two techniques. We performed a retrospective investigation of 202 tunneled hemodialysis catheters performed at our tertiary care hospital. Procedural data were obtained from the University of Wisconsin Department of Medicine, Nephrology Section Interventional Nephrology procedural database. Patient demographics, laboratory tests were obtained from the University of Wisconsin Hospital electronic medical record (EMR). Logistic regression was used to evaluate the effect of blind vs fluoro-guided placement on clinical outcomes, corrected for side of procedure, age, gender, previous history of catheter placement, diabetes mellitus (DM), and pre-procedural coagulation parameters. Baseline characteristics of 'blind' vs fluoro-guided groups differed with respect to side of procedure and DM (91.0% vs 79.6%, p = 0.02 and 43.30% vs 58.40%, p = 0.02, respectively). Non-fluoroscopic placement of catheters was associated with a decreased odds ratio of immediate success (OR = 0.1298, CI = 0.02 - 0.71). No difference in major or minor bleeding complications was discovered between the blind vs fluoro-guided group. Cost analysis revealed that performing the non-fluoroscopic technique as the preferred initial procedure would represent a substantial reduction in total bills submitted to third-party payers, including Medicare.
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Affiliation(s)
- A S Yevzlin
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison 53713, USA.
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Abstract
STUDY OBJECTIVE To compare triptan therapies for migraine in terms of the cost to treat 100 migraine attacks and the cost per successfully treated patient (cost/success), by analyzing utilization and reimbursement data from state Medicaid programs. DESIGN Pharmacoeconomic analysis. DATA SOURCE Clinical efficacy data were obtained from a previously published meta-analysis for 11 triptan-dose combinations: almotriptan 12.5 mg; eletriptan 20 and 40 mg; naratriptan 2.5 mg; rizatriptan 5 and 10 mg; sumatriptan 25, 50, and 100 mg; and zolmitriptan 2.5 and 5 mg. Triptan reimbursement data were obtained from the Medicaid Drug Rebate Program of seven geographically dispersed states (Florida, Georgia, Illinois, North Carolina, Ohio, Wisconsin, and West Virginia). MEASUREMENTS AND MAIN RESULTS Efficacy measures were derived based on data from the published meta-analysis that evaluated headache pain status at 2 and 24 hours after triptan dosing. Reimbursement data for the triptans were applied to a previously developed model of migraine treatment outcomes to calculate the cost to treat 100 migraine attacks and the cost/success. Sensitivity analysis around dosing assumptions was conducted to assess robustness of estimates. Across the seven states, the two treatments associated with the lowest cost to treat 100 migraine attacks were eletriptan 20 mg (range $1549-$1658) and eletriptan 40 mg ($1578-$1661). Naratriptan 2.5 mg (range $1734-$2018), sumatriptan 25 mg ($1853-1954), and zolmitriptan 5 mg ($1854-$1960) were associated with the highest cost to treat 100 migraine attacks. Eletriptan 40 mg was associated with the lowest cost/success (range $57.03-$60.05); naratriptan 2.5 mg ($99.39-$115.65), sumatriptan 25 mg ($107.11-$112.93), and rizatriptan 5 mg ($99.41-$111.25) were associated with the highest cost/success values. Changes in dosing assumptions did not significantly change the rank ordering of triptans across either economic end point. CONCLUSIONS Eletriptan 20- and 40-mg doses were shown to be associated with the lowest cost to treat 100 migraine attacks and the lowest cost/success in both the baseline and sensitivity analyses. These findings are consistent with results of similar economic analyses that compared multiple triptan therapies.
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Affiliation(s)
- C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, USA.
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