Is mild asthma truly mild? The patients' real-life setting

OBJECTIVES

Asthma exacerbations and, more rarely, fatal asthma attacks have been reported in mild asthma patients, suggesting poor disease control and awareness of its potential burden. Our study aimed to explore outside the hospital/specialist setting the perspective and disease treatment behavior of patients self-reporting a mild asthma diagnosis.

METHODS

Computer-Assisted Personal Interviewing (CAPI) technique was used to investigate the identified study population. Questions about diagnosis, symptoms, comorbidities, treatment strategy, ongoing assessments, and quality of life were administered.

RESULTS

Overall, 258 patients were considered for the analysis. As the most relevant results, 22% of them reported severe respiratory symptoms, 52% experienced at least one exacerbation/year, and 7% needed Emergency Room care. Sixty-six percent of the respondents assumed as needing short-acting bronchodilators only. Of note, 22% of patients were using oral steroids (OCS) intermittently and 72% of them considered their quality of life unsatisfying.

CONCLUSION

Outside the hospital/specialist setting, mild asthma burden is still not negligible and the treatment approach is not correct. In particular, the reported OCS use is disproportionate. Our data suggest that mild asthma, especially when self-assessed might be other than mild, suggesting that efforts to increase disease awareness, improve the disease control limiting the OCS abuse are required.

Surgical under-treatment of older adult patients with cancer: A systematic review and meta-analysis

BACKGROUND

Older patients with cancer often have lower surgery rates and survival than younger patients, but this may reflect surgical contraindications of advanced disease, comorbidities, and frailty - and not necessarily under-treatment.

OBJECTIVES

This review aims to describe variations in surgery rates and observed or net survival among younger (<75) and older (≥75) patients with breast, lung and colorectal cancer, while taking account of pre-existing health factors, in order to understand how under-treatment is defined and estimated in the literature.

METHOD

MEDLINE, EMBASE, Web of Science and PubMed databases were searched for studies reporting surgery rates and observed or net survival among younger and older patients with breast, lung, and colorectal cancer. Study quality was assessed using the Newcastle Ottawa Scale, and random effects meta-analyses were used to combine study results. The I-squared statistic and subgroup analyses were used to assess heterogeneity.

RESULTS

Thirty relatively high-quality studies of patients with breast (230,200; 71.9%), lung (77,573; 24.2%), and colorectal (12,407; 3.9%) cancers were identified. Compared to younger patients, older patients were less likely to receive surgical treatment for 1) breast cancer after adjusting for comorbidity, performance status (PS), functional status and patient choice, 2) lung cancer after accounting for stage, comorbidity, PS, and 3) colorectal cancer after adjusting for stage, comorbidity, and gender. The pooled unadjusted analyses showed lower surgery receipt in older patients with breast (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.78), lung (OR 0.54, 95% CI 0.39-0.75), and colorectal (OR 0.59, 95% CI 0.51-0.68) cancer. In separate analyses, older patients with breast, lung and colorectal cancer had lower observed and net survival, compared to younger patients.

CONCLUSIONS

Lower surgery rates in older patients may contribute to their poorer survival compared to younger patients. Future research quantifying under-treatment should include necessary clinical factors, patient choice, patient's quality of life and a statistically-robust approach, which will demonstrate how much of the survival deficit in older patients is due to their receiving lower surgery rates.

Observational outcomes in proliferative diabetic retinopathy patients following treatment with ranibizumab, panretinal laser photocoagulation or combination therapy - The non-interventional second year follow-up to the PRIDE study

PURPOSE

Ranibizumab monotherapy showed stronger effects on area of retinal neovascularization (NV) reduction while offering better visual acuity (VA) results than panretinal laser photocoagulation (PRP) monotherapy during the first 12 months of the PRIDE study. The second year of PRIDE was an observational, non-interventional follow-up, performed to evaluate long-term anatomical and functional outcomes in proliferative diabetic retinopathy (PDR) patients under real-life conditions, prior to the approval of ranibizumab for PDR.

METHODS

Seventy-three PDR patients (28 from the ranibizumab group; 20 from the PRP group; 25 from the combination group) were included in the observational follow-up phase and treated at the investigators discretion. Visual acuity (VA) measurements and retinal imaging were performed at Months 12, 18 and 24.

RESULTS

Mean (± SD) NV area in the ranibizumab monotherapy and combination follow-up groups increased from 3.16 ± 4.30 mm² and 1.13 ± 2.78 mm² at Month 12 to 6.09 ± 10.79 mm² and 2.14 ± 4.41 mm² at Month 18 and 10.00 ± 17.63 mm² and 3.26 ± 7.05 mm² at Month 24, respectively. In the PRP follow-up group, NV area declined from 5.44 ± 14.55 mm² at Month 12 to 1.22 ± 1.67 mm² at Month 18, but increased again to 4.05 ± 11.66 mm² at Month 24. During the observational phase, only 2 (6;8) patients in the ranibizumab (PRP;combination) follow-up group were treated with anti-VEGF medications, while 17 (6;10) patients received PRP laser therapy.

CONCLUSION

Discontinuation of ranibizumab treatment in PDR patients may result in an increase of NV area and VA loss. Tight monitoring of disease activity and continued treatment beyond the first year is needed to maintain disease control.

Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data

Objective

Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines.

Methods

We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of ‘pulmonary TB’ in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out‐of‐pocket (OOP) payments and effective reimbursement rates were analysed.

Results

A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients.

Conclusions

We found an alarming extent of TB over‐ and under‐treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.

Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high‐risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high‐risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co‐ordinating centre (‘hub’), for having surgery by the presence of surgical services on‐site, and for receiving high dose‐rate brachytherapy (HDR‐BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91–1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10–1.40), and more likely to receive additional HDR‐BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94–12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.

What's new?

More than one‐quarter of men with high‐risk or locally advanced prostate cancer in England do not receive radical treatment with radiotherapy or surgery, potentially owing to differences in treatment access. Here, prostate cancer service centralisation in England was investigated for potential impacts on treatment access. Among English patients in the National Prostate Cancer Audit database, centralisation had no impact on decisions to use radical treatment. It did, however, affect treatment option availability, with potential consequences for patient outcome. Patients were more likely to undergo surgery or high dose‐rate brachytherapy when diagnosed at hospitals with direct links to these services.

Post-fracture pharmacotherapy for women with osteoporotic fracture: analysis of a managed care population in the USA

Pharmacologic therapy is recommended to reduce future fracture risk. We examined osteoporosis medications dispensed to older women after first fracture. Only 23 % received therapy during the first year post-fracture. Prior osteoporosis therapy, a prior osteoporosis diagnosis, and older age were good predictors of post-fracture osteoporosis therapy.

INTRODUCTION

Pharmacologic therapy is recommended after osteoporotic fracture to reduce future fracture risk. The objective of this retrospective study was to examine osteoporosis therapy dispensed to women post-fracture.

METHODS

We identified women ≥50 years old in a large administrative claims database from 2003 to mid-2012 who were continuously enrolled 2 years before (baseline) and 1 year after first osteoporotic fracture. Exclusions were Paget's disease or malignant neoplasm. Pre- and post-fracture osteoporosis therapies (oral and parenteral) were assessed overall and by fracture site.

RESULTS

A total of 47,171 women of mean (SD) age of 63 (10) years were eligible; fractures included 8 % hip, 17 % vertebral, 73 % non-hip/non-vertebral, and 3 % multiple fracture sites. Only 18 % received osteoporosis therapy within 90 days and 23 % within 1 year post-fracture. Overall, 19 % of women had a prior osteoporosis diagnosis; 20 % had received osteoporosis therapy during baseline. Of 37,649 (80 %) women without baseline therapy, only 9 % initiated pharmacologic therapy within 1 year. The adjusted odds ratio (OR) of therapy within 1 year post-fracture was significantly greater for women who had received baseline osteoporosis therapy (versus none) and who had vertebral (OR 12.7, 95 % confidence interval (CI) 11.2-14.5), hip (15.2, 12.5-18.7), or non-hip/non-vertebral fracture (34.4, 31.7-37.3). Other significant predictors included pre-fracture osteoporosis diagnosis (1.6, 1.4-1.7) and older age (OR range, 1.3-1.7). Treatment adherence was significantly better among women with baseline osteoporosis diagnosis.

CONCLUSIONS

The substantial post-fracture treatment gap represents an important unmet need for women with osteoporotic fractures. Fracture liaison or adherence programs could lead to improved post-fracture treatment rates.

CEPHEUS SA: a South African survey on the undertreatment of hypercholesterolaemia

AIM

The aim of the CEntralised Pan-South African survey on tHE Under-treatment of hypercholeSterolaemia (CEPHEUS SA) was to evaluate the current use and efficacy of lipidlowering drugs (LLDs), and to identify possible patient and physician characteristics associated with failure, if any, to achieve low-density lipoprotein cholesterol (LDL-C) targets.

METHODS

The survey was conducted in 69 study centres in South Africa and recruited consecutive consenting patients who had been prescribed LLDs for at least three months. One visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Physicians and patients completed questionnaires regarding their knowledge, awareness and perceptions of hypercholesterolaemia and the treatment thereof.

RESULTS

Of the 3 001 patients recruited, 2 996 were included in the final analyses. The mean age was 59.4 years, and 47.5% were female. Only 60.5 and 52.3% of patients on LLDs for at least three months achieved the LDL-C target recommended by the NCEP ATP III/2004 updated NCEP ATP III and the Fourth JETF/South African guidelines, respectively. Being male, older than 40 years, falling into the lower-risk categories, compliance with the medication regimen, and patient knowledge that the LDL-C goal had been reached, were associated with the highest probability of attaining LDL-C goals.

CONCLUSION

The results of this survey highlight the sub-optimal lipid control achieved in many South African patients taking lipid-lowering therapy.