Use of Disease-Modifying Treatments in Patients With Sickle Cell Disease

Importance

Despite hydroxyurea being an established treatment for sickle cell disease (SCD), it remains underused. The recent approval of the disease-modifying treatments (DMTs) l-glutamine, crizanlizumab, and voxelotor underscores the need to understand the uptake of DMTs in the current treatment landscape.

Objective

To explore characteristics that may be associated with DMT use and to describe observed patterns of yearly DMT use from 2014 to 2021.

Design, Setting, and Participants

This cross-sectional study used administrative claims data from Optum's deidentified Clinformatics Data Mart Database from January 1, 2014, to September 30, 2021, to identify adults and children with SCD. Data were analyzed from August 1, 2022, to August 28, 2023.

Exposure

Use of DMTs.

Main Outcomes and Measures

Patient characteristics across groups with varying patterns of DMT use and yearly patterns of prescription fills for hydroxyurea, crizanlizumab, voxelotor, and l-glutamine.

Results

A total of 5022 beneficiaries with SCD (2081 [41.4%] aged 18-45 years; 2929 [58.3%] female) were included in sample A (144 [2.9%] inconsistent users, 274 [5.5%] incident users, 892 [17.8%] consistent users, and 3712 [73.9%] non-DMT users). Inconsistent users had a higher prevalence of vaso-occlusive crises (mean [SD], 3.7 [4.7]), splenic complications (6 of 144 [4.2%]), pulmonary complications (36 of 144 [25.0%]), kidney disease (21 of 144 [14.6%]), acute chest syndrome (18 of 144 [12.5%]), and health care visits (eg, mean [SD] inpatient visits, 7.0 [10.7]) compared with the other use groups. Non-DMT users had the lowest prevalence of vaso-occlusive crises (mean [SD], 0.8 [2.4]), acute chest syndrome (109 of 3712 [2.9%]), and inpatient (mean [SD], 2.0 [6.6]) and emergency department (mean [SD], 0.7 [3.1]) visits and the highest proportion of adults 65 years and older (593 of 3712 [16.0%]). In sample B (6387 beneficiaries with SCD), hydroxyurea use modestly increased from 428 of 2188 participants (19.6%) in 2014 to 701 of 2880 (24.3%) in 2021. Use of l-glutamine increased briefly but gradually decreased throughout the study period. In 2021, out of 2880 participants, 102 (3.5%) had at least 1 fill for crizanlizumab and 131 (4.6%) had at least 1 fill for voxelotor. Overall, total DMT use increased from 428 of 2188 participants (19.6%) in 2014 to 815 of 2880 patients (28.3%) in 2021.

Conclusions and Relevance

In this cross-sectional analysis of adults and children with SCD, uptake of DMTs remained low from 2014 to 2021, despite the approval of newer therapies. Notable differences in patient characteristics across varied DMT exposure types necessitate further exploration into factors that facilitate DMT use and the creation of strategies to enhance DMT uptake.

Community-Based Service Use After Clozapine Treatment: A Mirror-Image Analysis of Public Claims Data

Although clozapine demonstrates unique efficacy for treatment-resistant schizophrenia, its impact on community-based services remains largely underexplored. The authors examined changes in use of community-based services after clozapine treatment among a sample of 163 patients with schizophrenia by using public claims data in Allegheny County, Pennsylvania. Mirror-image analyses of service utilization were used to compare the 180-day period before treatment initiation with the 180-day period that began after 6 months of adherent treatment, accounting for age, race, and gender. Across demographic variables, clozapine treatment was associated with increased use of community-based services and decreased use of psychiatric inpatient services (p<0.05, Bonferroni corrected), suggesting that clozapine treatment shifts service needs from emergency care to community-based care and recovery.

The effectiveness and value of AMX0035 and oral edaravone for amyotrophic lateral sclerosis: A summary from the Institute for Clinical and Economic Review's Midwest Comparative Effectiveness Public Advisory Council

DISCLOSURES: Funding for this summary was contributed by Blue Cross Blue Shield of MA, California Healthcare Foundation, The Patrick and Catherine Weldon Donaghue Medical Research Foundation, Arnold Ventures, and Kaiser Foundation Health Plan Inc., to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, AbbVie, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy Solutions, Express Scripts, Genentech/ Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health First, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer. Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, Sun Life Financial, uniQure, and United Healthcare. Mr Nikitin, Ms McKenna, Ms Richardson, and Drs Rind and Pearson are employed by ICER. Through their affiliated institutions, Drs Makam, Carlson, and Suh received funding from ICER for the work described in this summary.

Cost Effectiveness of Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cells in Patients with Knee Osteoarthritis

OBJECTIVES

The aim of this study was to assess the cost effectiveness of allogeneic umbilical cord blood-derived mesenchymal stem cells with sodium hyaluronate (hUCB-MSC) compared with microfracture in patients with knee cartilage defects caused by osteoarthritis (OA) in South Korea.

METHODS

A partitioned survival model approach was taken consisting of five mutually exclusive health states: excellent, good, fair, poor, and death over a 20-year time horizon. Utility values were obtained from a randomized clinical trial. Cost data were extracted from a database provided by the Health Insurance Review & Assessment Service, and the utilization of healthcare services was estimated from an expert panel of orthopedic surgeons using a structured questionnaire. The incremental cost-effectiveness ratio (ICER) in terms of quality-adjusted life-years (QALY) was calculated. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In the base case, the incremental costs of US$14,410 for hUCB-MSC therapy along with its associated QALY gain of 0.857 resulted in an ICER of US$16,812 (₩18,790,773) per QALY (95% confidence interval [CI] US$13,408-US$20,828) when compared with microfracture treatment from a healthcare payer perspective. From a societal perspective, the ICER was US$268 (₩299,255) per QALY (95% CI -US$2915 to US$3784). When using a willingness-to-pay threshold of US$22,367/QALY, the probability of hUCB being cost effectiveness compared with microfracture was 99% from the healthcare payer perspective and 100% from the societal perspective.

CONCLUSIONS

The study demonstrated that hUCB-MSC therapy was cost effective compared with microfracture when treating patients with knee OA. These findings should inform health policy decision makers about considerations for cost-effective therapy for treating knee OA to ultimately enhance population health.

Trends in endpoint use in pivotal trials and efficacy for US Food and Drug Administration–approved solid tumor therapies, 1995-2021

BACKGROUND: Many cancer therapies are now approved based on surrogate endpoints such as progression-free survival (PFS) to ensure that patients have speedy access to life-saving cancer medicines. However, the link between surrogate endpoints and overall survival (OS) is not well established in many cancers. OBJECTIVE: To characterize trends in endpoints used in pivotal trials leading to approval for US Food and Drug Administration (FDA)-approved solid tumor therapies and their efficacy from 1995 to 2021. METHODS: We reviewed the FDA Oncology (Cancer)/Hematologic Malignancies Approval Notifications webpage to extract data on median OS and PFS among solid tumor therapy approvals from 1995 to 2021. We summarized trends in percentage of trials reporting OS vs PFS, median OS and PFS, and trial designs. We conducted subgroup analyses for lung and breast cancer therapies. RESULTS: Median OS was reported more frequently until 2010 to 2012, when median PFS and OS were reported in 65.2% and 60.9% of trials, respectively. Between 1995 and 2021, there were no observable trends in median OS over time for solid tumor therapy approvals. Median PFS increased by 3.0 months over time. For lung cancer therapies, median OS increased by 6.8 months between the time periods of 1998-2000 and 2019-2021, whereas median PFS increased by 5.0 months between the time periods of 2007-2009 and 2019-2021. For breast cancer therapy, median OS slightly decreased over time, whereas median PFS has increased by 3.4 months since 1995. There has been a recent shift in use of single-arm trials leading to oncology drug approvals. CONCLUSIONS: There has been a transition from reporting OS to PFS, and median PFS has increased by 3 months while median OS has remained stable. The different trends in overall and progression-free survival highlights the challenge and importance of measuring the value of oncology drugs. DISCLOSURES: Dr Suh reports personal fees from Bayer US LLC.

Comparative effectiveness of larotrectinib versus entrectinib for the treatment of metastatic NTRK gene fusion cancers

Aim: To extrapolate clinical trial results to estimate and compare expected progression-free and overall life years (LYs) and quality-adjusted LYs (QALYs) for larotrectinib and entrectinib in patients with colorectal cancer (CRC), soft tissue sarcoma (STS) and brain metastases prior to treatment with larotrectinib or entrectinib. Methods: A naive direct comparison of larotrectinib versus entrectinib was made using partitioned survival modeling methods from clinical trial data. Results: Larotrectinib resulted in an additional 1.58 LYs (1.17 QALYs), 5.81 LYs (2.02 QALYs) and 1.01 LYs in CRC, STS and baseline brain metastases, respectively, compared with entrectinib. Conclusion: Larotrectinib provided life expectancy and QALY gains compared with entrectinib. Additional studies will be beneficial as more patients are treated and survival data develop to better inform comparative effectiveness results.

Latent Class Analysis of Prescribing Behavior of Primary Care Physicians in the Veterans Health Administration

BACKGROUND

Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these medications.

OBJECTIVE

To identify PCP groups based on their propensity to prescribe benzodiazepines, opioids, PPIs, and antibiotics, and patient and PCP characteristics associated with identified prescribing patterns.

DESIGN

Retrospective cohort study using VA data and latent class regression analyses to identify prescribing patterns among PCPs and examine the association of patient and PCP characteristics with class membership.

PARTICIPANTS

A total of 2524 full-time PCPs and their patient panels (n = 2,939,636 patients), from January 1, 2017, to December 31, 2018.

MAIN MEASURES

We categorized PCPs based on prescribing volume quartiles for the four drug classes, based on total days' supply dispensed of each medication by the PCP to their patients (expressed as days' supply per 1000 panel patient-days). We used latent class analysis to group PCPs based on prescribing and used multinomial logistic regression to examine patient and PCP characteristics associated with latent class membership.

KEY RESULTS

PCPs were categorized into four groups (latent classes): low intensity (23% of cohort), medium-intensity overall/high-intensity PPI (36%), medium-intensity overall/high-intensity opioid (20%), and high intensity (21%). PCPs in the high-intensity group were predominantly in the highest quartile of prescribers for all four drugs (68% in the highest quartile for benzodiazepine, 86% opioids, 64% PPIs, 62% antibiotics). High-intensity PCPs (vs. low intensity) were substantially less likely to be female (OR: 0.30, 95% CI: 0.21-0.42) or practice in the northeast versus other census regions (OR: 0.10, 95% CI: 0.06-0.17).

CONCLUSIONS

VA PCPs can be classified into four clearly differentiated groups based on their prescribing of benzodiazepines, opioids, PPIs, and antibiotics, suggesting an underlying typology of prescribing. High-intensity PCPs were more likely to be male.

A Computational Framework to Characterize the Cancer Drug Induced Effect on Aging Using Transcriptomic Data

Cancer treatments such as chemotherapies may change or accelerate aging trajectories in cancer patients. Emerging evidence has shown that “omics” data can be used to study molecular changes of the aging process. Here, we integrated the drug-induced and normal aging transcriptomic data to computationally characterize the potential cancer drug-induced aging process in patients. Our analyses demonstrated that the aging-associated gene expression in the GTEx dataset can recapitulate the well-established aging hallmarks. We next characterized the drug-induced transcriptomic changes of 28 FDA approved cancer drugs in brain, kidney, muscle, and adipose tissues. Further drug-aging interaction analysis identified 34 potential drug regulated aging events. Those events include aging accelerating effects of vandetanib (Caprelsa®) and dasatinib (Sprycel®) in brain and muscle, respectively. Our result also demonstrated aging protective effect of vorinostat (Zolinza®), everolimus (Afinitor®), and bosutinib (Bosulif®) in brain.

The potential long-term comparative effectiveness of larotrectinib vs standard of care for treatment of metastatic TRK fusion thyroid cancer, colorectal cancer, and soft tissue sarcoma

BACKGROUND: Larotrectinib is approved for patients with metastatic TRK fusion cancers, including differentiated thyroid (DTC), colorectal cancer (CRC), and soft tissue sarcoma (STS). Given the basket clinical trial design of larotrectinib, direct comparisons against standard of care in each of the mentioned cancers have not been assessed. Also, owing to the limited duration of follow-up in clinical trials, long-term outcomes for treatments are generally not known or estimated. OBJECTIVE: To compare expected life-years (LYs) and quality-adjusted life-years (QALYs) for patients with metastatic DTC, CRC, and STS who are eligible to receive larotrectinib against patients with unknown NTRK gene fusion status receiving standard-of-care therapy. METHODS: We developed a partitioned survival model to estimate the long-term comparative effectiveness of larotrectinib and standard of care for 3 tumor types. Larotrectinib survival data, assessed by independent review committee, were derived from an updated July 2020 analysis of 19, 8, and 23 adult patients (aged ≥ 18 years) with metastatic TRK fusion DTC, CRC, and STS, respectively. The DTC survival data also included 2 patients aged less than 18 years for a total of 21 patients. Survival estimates for standard of care were derived from published clinical trials. Progressionfree and overall survival for all treatments were estimated using survival distributions (Exponential, Weibull, Log-logistic, and Lognormal) fit to the available data. The final exponential form was selected based on goodness-of-fit and clinical plausibility. QALYs were estimated by adjusting the time spent in the preprogression and postprogression health states by utility weights derived from publicly available literature. RESULTS: Patients receiving larotrectinib experienced more LYs and QALYs compared with those receiving standard-of-care treatments across all 3 assessed cancer types. In DTC, patients receiving larotrectinib had 7.15-8.26 additional LYs (5.87-6.12 QALYs); in CRC, patients receiving larotrectinib had 1.26-1.27 additional LYs (1.00 QALYs); and in STS, patients receiving larotrectinib had 5.56 additional LYs (1.99 QALYs). CONCLUSIONS: Compared with standard of care in metastatic TRK wild-type cancers, larotrectinib is estimated to result in improved LY and QALY outcomes based on parametric extrapolations of intrial survival data. Because patient-level data were unavailable for adjusted analyses, a cross-trial comparison was performed. Given the limitations of this analytic approach and the small sample size for larotrectinib in trials, future studies should reassess the comparative effectiveness of larotrectinib vs standard of care as treated patients accrue and long-term survival data mature. DISCLOSURES: K. Suh, J. Carlson, and S. Sullivan report consulting fees from Bayer US LLC. F. Xia and T. Williamson are employees of Bayer US LLC. This study was funded by Bayer US LLC. The sponsor had no role in the design of the study and did not have any role in the execution, analyses, interpretation of the data, or decision to submit results.

Patterns of Utilization and Expenditure Across Multiple Sclerosis Disease-Modifying Therapies: A Retrospective Cohort Study Using Claims Data from a Commercially Insured Population in the United States, 2010–2019

Introduction

Comparisons of healthcare utilization and expenditure among multiple sclerosis (MS) disease-modifying therapies (DMTs) are limited.

Methods

In this retrospective cohort study using commercial insurance claims data of a US population (2010–2019), we compared healthcare utilization and costs in MS across different DMTs. We assigned patients to different treatment arms: no DMT (ND), high-efficacy (HE) DMT (alemtuzumab, B cell depletion, cladribine, and natalizumab), and standard-efficacy (SE) DMT (dimethyl fumarate, glatiramer acetate, interferon beta, sphingosine-1-phosphate receptor modulator, and teriflunomide). We obtained healthcare costs and occurrences of healthcare services: outpatient visits, emergency room visits, hospitalizations, MS-related magnetic resonance imaging (MRI). We quantified relapses (based on MS-related hospitalizations, as well as outpatient visits with prescription of high-dose steroids) and medical complexity (based on unique drug classes of prescriptions). We calculated covariate-adjusted incidence rate ratio of healthcare services using negative binomial regression with ND as reference and covariate-adjusted mean cumulative healthcare costs using a generalized linear model with log-link function and gamma distribution.

Results

Among the 25,932 patients with MS (mean age 52.8 years, 75.2% women), both HE (mean age 54.0 years, 76.2% women) and SE (mean age 43.9 years, 75.6% women) groups had more non-pharmacy healthcare utilization than ND (mean age 57.6 years, 75.4% women), including overall outpatient doctor visits, neurology visits, and MS-related MRIs as well as relapses and medical complexities. Relative to ND, both HE and SE groups had higher pharmacy costs and overall healthcare costs 12 months after treatment initiation, despite having lower or equivalent non-pharmacy medical costs. In patients on DMT, pharmacy costs accounted for up to 65% of overall healthcare costs with over 85% of pharmacy costs attributable to DMT costs.

Conclusion

DMT cost is a key driver of the overall healthcare expenditure in MS. Future comparative and cost-effectiveness studies integrating claims and electronic health records data with better balancing of patient characteristics are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00358-4.

Assessing surveillance utilization and value in commercially insured patients with colorectal cancer

OBJECTIVES

Real-world patterns of surveillance testing in colorectal cancer (CRC) and the effects on health and cost outcomes are largely unknown. Our objectives were to (1) assess trends in carcinoembryonic antigen (CEA) testing, CT scans, and colonoscopy utilization and (2) examine the value of CEA testing intensity by characterizing receipt of curative treatment for recurrence and measuring direct medical costs.

STUDY DESIGN

Prospective cohort study.

METHODS

We used an IBM MarketScan database to identify patients with a diagnosis of and treatment for CRC between 2008 and 2015. We used a negative binomial model to assess utilization of CEA testing and logistic models to assess utilization of CT scans and colonoscopies. We used a Cox proportional hazards model to assess surveillance intensity and time to curative treatment. We estimated direct medical costs using the Kaplan-Meier sample average estimator to account for censored costs.

RESULTS

We identified 3197 eligible patients. The mean numbers of CEA tests, CT scans, and colonoscopies remained relatively constant in the study period, but adherence to guidelines varied by surveillance. When categorizing individuals by their CEA utilization adherence to guidelines (perfect utilizers and overutilizers), overutilizers had an HR for curative treatment of 2.11 (95% CI, 1.46-3.05) relative to perfect utilizers. Although overutilizers underwent potentially curative procedures for recurrence at higher rates compared with perfect utilizers, direct medical costs were much higher in the overutilizer group.

CONCLUSIONS

Higher intensity of surveillance, beyond what is recommended by guidelines, may lead to earlier recurrence detection and subsequent treatment, but this is associated with significantly higher direct medical costs.

The potential long-term comparative effectiveness of larotrectinib versus regorafenib or trifluridine/tipiracil for treatment of metastatic TRK fusion colorectal cancer

41

Background: Colorectal cancer (CRC) is the third leading cause of cancer-related mortality in the US, driven primarily by those with metastatic disease. For patients with metastatic disease who have progressed through available first- and second-line options, the standard of care systemic therapies are regorafenib or trifluridine/tipiracil. Larotrectinib is approved for patients with TRK fusion advanced solid tumors including metastatic CRC. Our objective was to compare expected life-years (LYs) and quality-adjusted life-years (QALYs) for metastatic CRC patients eligible to receive larotrectinib, regorafenib or trifluridine/tipiracil. Methods: We developed a partitioned survival model to project long-term comparative effectiveness of larotrectinib vs. regorafenib or trifluridine/tipiracil. Larotrectinib survival data, assessed by independent review committee, were derived from a July 2020 analysis of 8 adult (≥18 years of age) metastatic TRK fusion CRC patients from the larotrectinib clinical trials program (NCT02122913, NCT02637687, and NCT02576431). Survival inputs for regorafenib and trifluridine/tipiracil were derived from the CORRECT trial (NCT01103323) and the RECOURSE trial (NCT01607957), respectively. Progression-free (PFS) and overall survival (OS) for larotrectinib, regorafenib, and trifluridine/tipiracil were estimated using survival distributions (Exponential, Weibull, Log-logistic, and Log-normal) fit to the available data. Exponential fits were used based on goodness-of-fit and clinical plausibility. QALYs were estimated by adjusting the time spent in the pre-progression and post-progression health states by health state utilities derived from publicly available literature. In accordance with standard practice in health economics and outcomes research on future health benefits, a constant discount rate of 3% was applied to the LYs and QALYs. Model uncertainty was evaluated using one-way sensitivity analysis and probabilistic sensitivity analysis with 10,000 simulations. Results: Larotrectinib resulted in 2.11 LYs and 1.60 QALYs compared to 0.83 LYs and 0.59 QALYs for regorafenib and 0.85 LYs and 0.60 QALYs for trifluridine/tipiracil. These estimates yielded additional gains for larotrectinib of 1.28 LYs (1.01 QALYs) and 1.26 LYs (0.99 QALYs) against regorafenib and trifluridine/tipiracil, respectively. Conclusions: In metastatic CRC, larotrectinib may produce substantial life expectancy and quality-adjusted life-year gains compared to regorafenib or trifluridine/tipiracil. Additional data with longer follow-up times will further inform this comparison.

The potential long-term comparative effectiveness of larotrectinib versus entrectinib for treatment of metastatic TRK fusion colorectal cancer

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Background: Commonly used systemic therapies in metastatic colorectal cancer (CRC) for patients who have progressed through available first- and second-line regimens are regorafenib or trifluridine/tipiracil. For the subset of metastatic CRC patients with neurotrophic receptor tyrosine kinase ( NTRK) gene fusions, there are two additional approved options, larotrectinib or entrectinib. Our objective was to estimate and compare expected life-years (LYs) and quality-adjusted life-years (QALYs) for metastatic TRK fusion CRC patients receiving larotrectinib versus entrectinib. Methods: We developed a partitioned survival model to project long-term comparative effectiveness of larotrectinib vs. entrectinib. Extrapolation was necessary as follow-up for both drugs was less than three years at the time of data reporting. Survival data for larotrectininb, assessed by independent review committee, were derived from a July 2020 analysis of 8 adult (≥18 years of age) TRK fusion CRC patients from the larotrectinib clinical trials program (NCT02122913, NCT02637687, and NCT02576431). Survival inputs for entrectinib were derived from 7 TRK fusion CRC patients from an October 2018 integrated analysis of three single arm trials (EudraCT 2012-000148-88, NCT02097810, and NCT02568267). Progression-free survival (PFS) and overall survival (OS) for both treatments were estimated using parametric survival distributions (Exponential, Weibull, Log-logistic, and Log-normal) fit to the available data. Exponential curves were used based on goodness-of-fit and clinical plausibility. QALYs were estimated by adjusting the time spent in the pre-progression and post-progression health states by health state utilities derived from publicly available literature. A constant discount rate of 3% was applied to LYs and QALYs. Model uncertainty was evaluated using one-way sensitivity analysis and probabilistic sensitivity analysis with 10,000 simulations. Results: Larotrectinib resulted in 2.11 LYs and 1.60 QALYs compared to 0.53 LYs and 0.41 QALYs for entrectinib. These estimates yielded additional gains for larotrectinib of 1.58 LYs and 1.19 QALYs against entrectinib. Conclusions: In metastatic TRK fusion CRC, larotrectinib may produce substantial life expectancy and quality-adjusted life-year gains compared to entrectinib. Additional data with longer follow-up times will further inform this comparison.

Trends in healthcare expenditures and resource utilization among a nationally representative population with opioids in the United States: a serial cross-sectional study, 2008 to 2017

BACKGROUND

Previous reports on healthcare costs and expenditures associated with populations prescribed an opioid primarily focused on populations who chronically use opioids or have opioid use disorder. However, studies that characterize the healthcare and expenditures costs among the wider number of people prescribed opioids in a nationally representative population are unavailable. We sought to characterize the healthcare costs and expenditures associated with a population prescribed an opioid in the U.S. from 2008 to 2017.

METHODS

A serial cross-sectional design was used to compare the economic burden of adult household respondents who were prescribed and not prescribed an opioid using pooled data from the Medical Expenditure Panel Survey (MEPS) between 2008 and 2017. Respondents with an opioid prescription were matched to respondents without an opioid prescription using propensity score match methods with survey weights. Two-part generalized linear models were used to estimate the survey-weighted annual healthcare expenditures and resource utilization adjusting for multiple covariates. Additionally, 10-year trend comparisons between the groups were performed. Costs were adjusted to 2019 US dollars.

RESULTS

There was a weighted total of 31,696,671 respondents with an opioid and 31,536,639 respondents without an opioid after propensity score matching. The sample had a mean (SD) age of 50.63 years (18.03), 58.9% females, and 81.6% Whites. Total annual economic burden among RPOs was $524 billion. Annual total expenditures per respondent with and without an opioid were $16,542 and $7067, respectively (P < 0.001). Similarly, adjusted prescription, outpatient, emergency department, and inpatient expenditures were significantly higher for respondents with an opioid compared to respondents without an opioid. Average annual increases in expenditures were significantly greater among respondents with an opioid compared to respondents without an opioid for total (+$185; 95% CI: $37-$334) and prescription (+$78; 95% CI: $28-$128) expenditures. There were no differences in the average annual trends for outpatient, emergency department, and inpatient expenditures between respondents with and without an opioid.

CONCLUSIONS

Respondents with an opioid prescription had higher healthcare expenditures and resource utilization compared to respondents without an opioid prescription from 2008 to 2017. Specifically, significant annual increases were observed for total and prescription expenditures. Additionally, 10-year trends in total and prescription expenditures were higher among respondents with an opioid than respondents without an opioid.

A systematic review of cost-effectiveness analyses across the acute kidney injury landscape

Introduction: Acute kidney injury (AKI) is a complex and common condition associated with increased morbidity, mortality, and costs. Evidence from cost-effectiveness analysis (CEA) have targeted various aspects of AKI including detection with biomarkers, treatment with renal replacement therapy, and prevention when using contrast media. However, there has not been a systematic review of these studies across the entirety of AKI.Areas covered: PubMed, Embase, and Cochrane library were used to identify CEA studies that involved AKI from 2004 onwards. These studies compared AKI treatment through renal replacement therapies (n = 6), prevention of contrast-induced-AKI (CI-AKI) using different media (n = 3), and diagnosis with novel biomarkers (n = 2). Treatment strategies for AKI focused on continuous versus intermittent renal replacement therapy. While there was no consensus, the majority of studies favored the continuous form. For contrast media, both studies found iodixanol to be cost-effective compared to iohexol for preventing CI-AKI. Additionally, novel biomarkers showed potential to be cost-effective in risk assessment and detection of AKI.Expert opinion: Consistent criteria such as a lifetime time horizon would allow for better model comparisons. Further research on clinical parameters to capture transition probabilities between stages within AKI and progression to downstream kidney disease is needed.

Cost-effectiveness of opicapone and entacapone in reducing OFF-time in Parkinson's disease patients treated with levodopa/carbidopa

AIMS

To assess from a US payer perspective the relative cost-effectiveness of the catechol-O-methyltransferase inhibitors opicapone and entacapone when used adjunctively to levodopa/carbidopa (LD/CD) in patients with Parkinson's disease (PD), based on the drugs' effects to reduce absolute OFF-time hours in PD patients.

MATERIALS AND METHODS

A Markov model was created to estimate cost-effectiveness of adjunctive opicapone treatment compared with adjunctive entacapone treatment in a synthetic cohort of 1,000 patients with PD taking LD/CD. Clinical inputs were derived from clinical trials, published literature, and expert opinion. Cost data (in 2018 US dollars) were obtained from the Centers for Medicare & Medicaid Services, the Kaiser Family Foundation, and Analy$ource. Cost-effectiveness outcomes included incremental cost per OFF-time hours avoided, cost per life year gained, and cost per quality-adjusted life year (QALY) gained. Outcomes were projected over a 25-year lifetime horizon and discounted at 3% annually.

RESULTS

Opicapone treatment was associated with an average of 1,187 fewer OFF-time hours per patient and an increase of 0.07 QALYs compared with entacapone. Total lifetime costs for opicapone were $3,100 higher than entacapone, resulting in an incremental cost-effectiveness ratio of $46,900 per QALY. One-way sensitivity analyses showed the model was most sensitive to mean OFF-time hours associated with opicapone and entacapone. Probabilistic sensitivity analysis suggested a 60-65% probability that opicapone was cost-effective relative to entacapone at any willingness-to-pay threshold ≥$5,000.

LIMITATIONS

There exists a single head-to-head clinical trial comparing the effectiveness of opicapone with entacapone, thus the clinical inputs regarding relative treatment effect of the drugs to reduce OFF-time hours in PD patients receiving LD/CD were derived from that single non-inferiority trial.

CONCLUSIONS

Add-on treatment with opicapone in PD patients receiving LD/CD appeared to be cost-effective compared with entacapone.

Effect of Treatment with the PD-1/PD-L1 Inhibitors on Key Health Outcomes of Cancer Patients

BACKGROUND

Recent studies have shown that treatment with the programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor class could significantly improve survival outcomes in several oncology indications. However, there is some clinical uncertainty.

OBJECTIVE

This study aimed to obtain high-level estimates of the impact of treatment with PD-1/PD-L1 inhibitor class to oncology treatment on key health outcomes in real-world situations and to inform public health policy decisions about cancer care after reducing uncertainties around new immuno-oncology therapy options in South Korea.

METHODS

A model was developed to estimate the impact of PD-1/PD-L1 inhibitors on outcomes in situations wherein both anti-PD-1/PD-L1s and standard of care (SOC) were available versus SOC only. A partitioned survival model was utilized to estimate the impact of introducing anti-PD-1/PD-L1s on outcomes, including life-years gained, quality-adjusted life-years gained, progression-free survival-years obtained, and grade 3 or higher adverse events avoided for six indications over 5 years. An exponential distribution was fitted to the survival function of the SOC based on visual inspection. Outcomes associated with anti-PD-1/PD-L1s were estimated using a piecewise modeling approach with Kaplan-Meier analysis followed by best-fitting survival analysis. The incident number of patients and market share of anti-PD-1/PD-L1s during 2020-2024 were projected using published literature and Korean market survey data. Sensitivity analyses were performed to test the uncertainty of input parameters.

RESULTS

During the next 5-year period (2020-2024), introducing the anti-PD-1/PD-L1 class led to a gain of 22,001 life-years (+ 31%), 19,073 quality-adjusted life-years (+ 38%), and 22,893 progression-free survival-years (+ 82%); it also avoided 3610 adverse events (- 11%) compared with SOC alone. Most adverse events associated with anti-PD-1/PD-L1s were attributed to combination therapy with cytotoxic chemotherapy (91%). In a scenario wherein the time to reimbursement of the anti-PD-1/PD-L1s was accelerated by 1 year, the life-years gained increased by 14% compared with the base-case scenario.

CONCLUSIONS

Anti-PD-1/PD-L1 therapy is expected to provide marked survival benefits for patients with cancer. This study demonstrated the potentially beneficial health impacts of utilizing the anti-PD-1/PD-L1 class at the population level. The findings could inform health policy decision makers about cancer care and ultimately enhance population health through rapid access to innovative cancer drugs.

Effectiveness of Gastric Bypass Versus Gastric Sleeve for Cardiovascular Disease: Protocol and Baseline Results for a Comparative Effectiveness Study

Background

When compared with conventional weight loss strategies, bariatric surgery results in substantially greater durable weight loss and rates of disease remission.

Objective

The ENGAGE CVD (Effectiveness of Gastric Bypass versus Gastric Sleeve for Cardiovascular Disease) cohort study aimed to provide population-based, comprehensive, rigorous evidence for clinical and policy decision making regarding the choice between gastric bypass and gastric sleeve for overall cardiovascular disease (CVD) risk reduction, risk factor remission, and safety.

Methods

The cohort had 22,095 weight loss surgery patients from a large integrated health care system in Southern California assembled from 2009 to 2016 who were followed up through 2018. Bariatric surgery patients were followed up for the length of their membership in the health care system. Of the patients who had at least five years of follow-up (surgery between 2009 and 2013), 85.86% (13,774/16,043) could contribute to the outcome analyses for the ENGAGE CVD cohort.

Results

Patients in the ENGAGE CVD cohort were 44.6 (SD 11.4) years old, mostly women (17,718/22,095; 80.19%), with 18.94% (4185/22,095) non-Hispanic black and 41.80% (9235/22,095) Hispanic, and had an average BMI of 44.3 (SD 6.9) kg/m² at the time of surgery. When compared with patients who did not contribute data to the 5-year outcome analysis for the ENGAGE CVD cohort (2269/16,043; 14.14%), patients who contributed data (13,774/16,043; 85.86%) were older (P=.002), more likely to be women (P=.02), more likely to be non-Hispanic white (P<.001), more likely to have had an emergency department visit in the year before surgery (P=.006), less likely to have a mental illness before surgery (P<.001), and more likely to have had a CVD event at any time before surgery (P<.001).

Conclusions

This study had one of the largest populations of gastric sleeve patients (n=13,459). The 5-year follow-up for those patients who had surgery between 2009 and 2013 was excellent for a retrospective cohort study at 85.86% (13,774/16,043). Unlike almost any study in the literature, the majority of the ENGAGE CVD cohort was racial and ethnic minority, providing a rare opportunity to study the effects of bariatric surgery for different racial and ethnic groups, some of whom have the highest rates of severe obesity in the United States. Finally, it also used state-of-the-art statistical and econometric comparative effectiveness methods to mimic the effect of random assignment and control for sources of confounding inherent in large observational studies.

International Registered Report Identifier (IRRID)

RR1-10.2196/14936

Correction to: CD4 T cell count is positively associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

Two sentences in the Discussion section were incorrect.

CD4 T cell count is inversely associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

HIV-infected men under the age of 50 years had a lower bone mass compared to that of HIV-uninfected men. Lower CD4 T cell counts, independent of whether antiretroviral therapy (ART) was used, were associated with lower BMD. HIV-infected patients with low CD4 T cell counts may need follow-up and intervention regarding bone health, including younger patients.

INTRODUCTION

HIV-infected patients have a low bone mineral density (BMD) owing to multifactorial interaction between common osteoporosis risk factors and HIV-related factors, including chronic inflammation and ART. Although HIV infection and ART might affect bone metabolism, little data is available for patients aged under 50 years. We aimed to investigate the association of HIV infection-induced low CD4 T cell counts and ART with BMD in men aged under 50 years.

METHODS

We performed an age- and body mass index-matched case-control study. BMD values of HIV-infected and HIV-uninfected men (< 50 years) were compared, and HIV-infected men were stratified by CD4 T cell counts and ART use.

RESULTS

After adjusting confounders, HIV-infected men with CD4 T cell counts ≥ 500 cells/μL (n = 28) and < 500 cells/μL (n = 139) had lower BMD at the femoral neck (FN, p < 0.001) and total hip (TH, p < 0.001) than HIV-uninfected men (n = 167). HIV-infected men with CD4 T cell counts < 500/μL had lower BMD at the lumbar spine (LS, p = 0.034) than those with counts of ≥ 500 cells/μL, but not at FN and TH. The CD4 T cell count (γ = 0.169, p = 0.031) was positively correlated with BMD at LS. There was no significant difference in the BMD (p = 0.499-> 0.999) between the ART-naïve (n = 75) and ART-user group (n = 92).

CONCLUSIONS

Despite their relatively younger age, HIV-infected men had a lower BMD than HIV-uninfected men. Lower CD4 T cell counts, irrespective of ART, might result in lower bone mass.

Defining and Managing High-Priced Cures: Healthcare Payers' Opinions

OBJECTIVES

Recent regulatory approvals of potentially curative but high-cost treatments have made these therapies a focus of health policy discussions. Cures present new challenges to healthcare payers because they have high upfront costs but have life-long health benefits. The objectives of this study are to understand how healthcare payers define and manage cures. We investigated payers' views on key features of curative treatments and the affordability and value challenges they present.

METHODS

We conducted semistructured interviews in 2016 with key informants in US payer organizations. Interviewees were directly involved in coverage determination for highly effective and curative therapies.

RESULTS

We contacted 24 individuals and 18 participated. When asked what aspects of cures were important for coverage determination, an equal percentage of respondents (61% each) mentioned clinical and economic factors. In defining a cure, half of respondents included an economic element such as no downstream costs associated with the disease. When asked about challenges, 72% of respondents mentioned uncertainty regarding long-term outcomes and 56% mentioned membership churn and competition.

CONCLUSIONS

Payers expressed a novel definition of a cure-which we call a "healthcare cost cure"-that captures both the clinical and economic consequences of treatment. This definition may be more pertinent in fragmentary financing systems that unevenly distribute cure costs and benefits across payers. Overall findings indicate that decision makers desire evidence to ensure that the long-term real-world consequences of covering cures match the expected benefits. Future policies need to balance upfront acquisition costs with downstream financial benefits.

Paying for Cures: How Can We Afford It? Managed Care Pharmacy Stakeholder Perceptions of Policy Options to Address Affordability of Prescription Drugs

BACKGROUND

High-priced medications with curative potential, such as the newer hepatitis C therapies, have contributed to the recent growth in pharmaceutical expenditure. Despite the obvious benefits, health care decision makers are just beginning to grapple with questions of how to value and pay for curative therapies that may feature large upfront cost, followed by health benefits that are reaped over a patient's lifespan. Alternative policy options have been proposed to promote high value and financially sustainable use of these therapies. It is unclear which policy options would be most acceptable to health care payer and biomedical manufacturer stakeholders.

OBJECTIVES

To (a) briefly review pharmaceutical policy options to address health system affordability and (b) assess the acceptability of alternative policy options to health care payers and biomedical manufacturers before and after an Academy of Managed Care Pharmacy (AMCP) continuing pharmacy education (CPE) session.

METHODS

We searched MEDLINE and Cochran databases for pharmaceutical policy options addressing affordability. With input from a focus group of managed care professionals, we developed CPE session content and an 8-question survey focusing on the most promising policy options. We fielded the survey before and after the CPE session, which occurred as part of the 2016 AMCP Annual Meeting. We first conducted a chi-squared goodness-of-fit test to assess response distributions. Next, we tested how responses differed before and after by using an ordered logit and a multinomial logit to model Likert scale and unordered responses, respectively.

RESULTS

Although risk-sharing payments over time remained the most favorable choice before (37%) and after (35%) the CPE session, this choice was closely followed by HealthCoin after the session, which increased in favorability from 4% to 33% of responses (P = 0.001). About half of the respondents (54%) indicated that legislative change is the most significant barrier to the implementation of any policy.

CONCLUSIONS

As high-cost curative drugs reach the market, managed care stakeholders need information from a balanced education source regarding alternative policies to address affordability. We found that after the AMCP CPE session, risk-sharing payments over time and HealthCoin were the most favorable options.

DISCLOSURES

No funding was provided for this research. Carlson reports consulting fees from Genentech, Pfizer, and Seattle Genetics. The other authors have nothing to disclose. Study concept and design were contributed by Yeung, Garrison, and Carlson. Yeung collected the data, which were interpreted by Yeung and Basu. The manuscript was written by Yeung, Suh, and Bansal and revised by Yeung. A portion of this research was presented at the Academy of Managed Care & Specialty Pharmacy Annual Meeting as a continuing education session entitled "Paying for Cures: How Can We Afford It?" on April 20, 2016, in San Francisco, California.

Cost Effectiveness of Alectinib vs. Crizotinib in First-Line Anaplastic Lymphoma Kinase-Positive Advanced Non-Small-Cell Lung Cancer

BACKGROUND

The recently completed ALEX trial demonstrated that alectinib improved progression-free survival, and delayed time to central nervous system progression compared with crizotinib in patients with anaplastic lymphoma kinase-positive non-small-cell lung cancer. However, the long-term clinical and economic impact of using alectinib vs. crizotinib has not been evaluated. The objective of this study was to determine the potential cost utility of alectinib vs. crizotinib from a US payer perspective.

METHODS

A cost-utility model was developed using partition survival methods and three health states: progression-free, post-progression, and death. ALEX trial data informed the progression-free and overall survival estimates. Costs included drug treatments and supportive care (central nervous system and non-central nervous system). Utility values were obtained from trial data and literature. Sensitivity analyses included one-way and probabilistic sensitivity analyses.

RESULTS

Treatment with alectinib vs. crizotinib resulted in a gain of 0.91 life-years, 0.87 quality-adjusted life-years, and incremental costs of US$34,151, resulting in an incremental cost-effectiveness ratio of US$39,312/quality-adjusted life-year. Drug costs and utilities in the progression-free health state were the main drivers of the model in the one-way sensitivity analysis. From the probabilistic sensitivity analysis, alectinib had a 64% probability of being cost effective at a willingness-to-pay threshold of US$100,000/quality adjusted life-year.

CONCLUSIONS

Alectinib increased time in the progression-free state and quality-adjusted life-years vs. crizotinib. The marginal cost increase was reflective of longer treatment durations in the progression-free state. Central nervous system-related costs were considerably lower with alectinib. Our results suggest that compared with crizotinib, alectinib may be a cost-effective therapy for treatment-naïve patients with anaplastic lymphoma kinase-positive non-small-cell lung cancer.

Healthcare Costs and Resource Utilization in Patients with Multiple Sclerosis Relapses Treated with H.P. Acthar Gel(®)

Introduction

Multiple sclerosis (MS) is an autoimmune disorder with large annual costs. This study evaluated utilization and costs for the management of MS relapses with H.P. Acthar^® Gel (repository corticotropin injection; Acthar; Mallinckrodt) compared to receipt of plasmapheresis (PMP) or intravenous immunoglobulin (IVIG) among patients with MS who experienced multiple relapses.

Methods

We identified patients with MS diagnoses who had relapses treated with intravenous methylprednisolone (IVMP), the first-line treatment for MS relapse. Patients who were treated for the subsequent relapses were eligible for the study. We analyzed 12- and 24-month healthcare utilization and costs among patients who received Acthar prescriptions compared to patients who were treated with PMP/IVIG using generalized linear and logistic regression models to calculate unadjusted and adjusted means and 95% confidence intervals.

Results

For the 12-month analysis, a total of 213 patients received Acthar prescriptions and 226 were treated with PMP or IVIG. Patients who received Acthar prescriptions were similar to those who received other treatments in terms of most demographic variables. Acthar recipients had fewer hospitalizations (0.2 vs. 0.4; P = 0.01) and received fewer outpatient services (29 vs. 43; P < 0.0001) but received more prescription medications (36 vs. 30; P < 0.0001) compared to recipients of PMP/IVIG. Patients who received Acthar prescriptions had lower inpatient and outpatient costs ($15,000 lower; P = 0.001; and $54,000 lower; P < 0.0001, respectively) but similar total costs. Similar results were seen in the cohort with 24 months of outcome data.

Conclusion

Acthar may be a useful treatment option compared to PMP/IVIG for patients with MS experiencing multiple relapses.

Funding

This study was funded by a grant to the University of Washington from Mallinckrodt Pharmaceuticals.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0363-0) contains supplementary material, which is available to authorized users.

Analysis of Glycemic Control of a Pharmacist-Led Medication Management Program in Patients with Type 2 Diabetes

BACKGROUND

An integrated health care system with its own regional health plan located in Texas implemented a pharmacist-led diabetes medication management program (MMP) to treat type 2 diabetic patients (baseline A1c > 7.5%). The MMP formed collaborative practice agreements with the system's physicians to allow ambulatory care pharmacists to modify and adjust diabetic drug regimens when appropriate. Enrolled MMP patients received personalized visits with ambulatory care pharmacists and a copay waiver on diabetes medications.

OBJECTIVE

To study the outcomes of an outpatient, pharmacist-led MMP, along with a copay waiver on diabetes drugs, in treating adults with type 2 diabetes mellitus over a 2-year period compared with standard care practice.

METHODS

This retrospective study employed a quasi-experimental design and used medical claims, pharmacy claims, eligibility data, and electronic medical records. Patients aged 18 to 62 years, who were diagnosed with type 2 diabetes mellitus, and had at least 1 diabetes-related pharmacy claim in the year before the MMP, as well as continuous enrollment in the health plan, were included. Patients enrolled in the pharmacist-led MMP for at least 2 years (n =75) were matched to standard care patients (n =75) on age, gender, baseline A1c, insulin use, and physical comorbidity. The primary outcome was the 2-year change in A1c. Secondary outcomes included inpatient costs, outpatient costs, and pharmacy costs from the baseline period (year before enrollment) compared with the follow-up period (second year of enrollment).

RESULTS

After matching MMP patients (n = 75) to control patients (n = 75), the baseline A1c (9.30 and 9.26), the mean age (53.0 and 53.3, respectively), the Selim Physical Score (3.32 and 3.26, respectively), and the use of insulin (56.0% and 56.0%, respectively) were similar in both groups. MMP patients had a greater mean reduction in A1c compared with standard care patients (-1.24 vs. -0.59, P = 0.009) from baseline to after 2 years. After 2 years, the A1c for MMP patients was significantly lower compared with control patients (8.06 vs.8.67, respectively, P = 0.014). There was also a difference in A1c after 1 year for MMP patients versus control patients (8.18 and 8.69, respectively, P = 0.012).

CONCLUSIONS

A pharmacist-led diabetes MMP, combined with a diabetes drug copay waiver, was effective in significantly reducing A1c over a 2-year period for type 2 diabetic patients in this regional health plan.

Economic Burden of COPD in the Presence of Comorbidities

BACKGROUND

The morbidity and mortality associated with COPD exacts a considerable economic burden. Comorbidities in COPD are associated with poor health outcomes and increased costs. Our objective was to assess the impact of comorbidities on COPD-associated costs in a large administrative claims dataset.

METHODS

This was a retrospective observational study of data from the Truven Health MarketScan Commercial Claims and Encounters and the MarketScan Medicare Supplemental Databases from January 1, 2009, to September 30, 2012. Resource consumption was measured from the index date (date of first occurrence of non-rule-out COPD diagnosis) to 360 days after the index date. Resource use (all-cause and disease-specific [ie, COPD- or asthma-related] ED visits, hospitalizations, office visits, other outpatient visits, and total length of hospital stay) and health-care costs (all-cause and disease-specific costs for ED visits, hospitalizations, office visits, and other outpatient visits and medical, prescription, and total health-care costs) were assessed. Generalized linear models were used to evaluate the impact of comorbidities on total health-care costs, adjusting for age, sex, geographic location, baseline health-care use, employment status, and index COPD medication.

RESULTS

Among 183,681 patients with COPD, the most common comorbidities were cardiovascular disease (34.8%), diabetes (22.8%), asthma (14.7%), and anemia (14.2%). Most patients (52.8%) had one or two comorbidities of interest. The average all-cause total health-care costs from the index date to 360 days after the index date were highest for patients with chronic kidney disease ($41,288) and anemia ($38,870). The impact on total health-care costs was greatest for anemia ($10,762 more, on average, than a patient with COPD without anemia).

CONCLUSIONS

Our analysis demonstrated that high resource use and costs were associated with COPD and multiple comorbidities.

Assessing the importance of predictors in unplanned hospital readmissions for chronic obstructive pulmonary disease

PURPOSE

The all-cause readmission rate within 30 days of index admissions for chronic obstructive pulmonary disease (COPD) was approximately 21% in the United States in 2008. This study aimed to examine patient and clinical characteristics predicting 30-day unplanned readmissions for an initial COPD hospitalization and to determine those predictors' importance.

PATIENTS AND METHODS

A retrospective study was conducted in patients with COPD-related hospitalizations using commercial claims data from 2010 to 2012. The primary outcome was all-cause unplanned readmission, with secondary outcomes being COPD as primary diagnosis and COPD as any diagnosis unplanned readmissions. Factors predicting unplanned readmissions encompassed demographic, pharmacy, and medical variables identified at baseline and during the index hospitalization. Dominance analysis was conducted to rank the predictors in terms of importance, defined as the contribution to change in model fit of a predictor by itself and in combination with other predictors.

RESULTS

After applying the inclusion and exclusion criteria, 18,282 patients with index COPD-related admissions were identified. Among them, the rates of unplanned readmissions with COPD as primary diagnosis, COPD as any diagnosis, and all-cause were 2.6%, 5.6%, and 7.3%, respectively. For each outcome, the readmission group was slightly older, had a greater COPD severity score, and required a longer length of stay. Moreover, the readmission group had larger proportions of patients with comorbidities, dyspnea/shortness of breath, intensive care unit stay, or ventilator use, compared to the non-readmission group. Dominance analysis revealed that the three most important predictors - heart failure/heart disease, anemia, and COPD severity score - accounted for 56% of the predicted variance in all-cause unplanned readmissions.

CONCLUSION

Overall, COPD severity score and heart failure/heart disease emerged as important factors in predicting 30-day unplanned readmissions across all three outcomes. Results from dominance analysis suggest looking beyond COPD-specific complications and focusing on comorbid conditions highly associated with COPD in order to lower all-cause unplanned readmissions.

Health economics and outcomes research fellowship practices reviewed

The guidelines for health economics and outcomes research (HEOR) fellowship training programs devised by the American College of Clinical Pharmacy (ACCP) and the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) suggest that continuous improvements are made to ensure that postgraduate training through didactic and professional experiences prepare fellows for HEOR research careers. The HEOR Fellowship Program at Novartis Pharmaceuticals Corporation was standardized to enhance the fellows' HEOR research understanding and align professional skill sets with the ACCP-ISPOR Fellowship Program Guidelines. Based on feedback from an internal task force comprised of HEOR employees and current and former fellows, the HEOR Fellowship Program was normatively and qualitatively assessed to evaluate the current curricular program. Fellowship program activities were instituted to ensure that the suggested minimum level requirements established by the guidelines were being met. Research opportunities enabling fellows to work hand-in-hand with other fellows and HEOR professionals were emphasized. Curricular enhancements in research methodology and professional training and development, and materials for a structured journal club focusing on specific methodological and HEOR research topics were developed. A seminar series (e.g., creating SMART Goals, StrengthsFinder 2.0) and professional courses (e.g., ISPOR short courses, statistics.com) were included to enhance the fellows' short- and long-term professional experience. Additional program attributes include an online reference library developed to enrich the current research facilities and a Statistical Analysis Software training program. Continuously assessing and updating HEOR fellowship programs keeps programs up-to-date in the latest HEOR concepts and approaches used to evaluate health care, both professionally and educationally.

Studies on human pregnancy-induced insulin-like growth factor (IGF)-binding protein-4 proteases in serum: determination of IGF-II dependency and localization of cleavage site

Insulin-like growth factor (IGF)-binding protein-4 (IGFBP-4), a consistent inhibitor of IGF action, is subject to proteolytic cleavage by the IGF-II-dependent IGFBP-4 protease. However, regulation of the IGF-II-dependent IGFBP-4 protease in vivo is not known. As IGFBP proteases are known to be triggered during pregnancy, we systematically evaluated the changes in IGFBP-4 proteolysis by serum collected throughout human pregnancy. Results from in vitro protease assays using recombinant IGFBP-4 revealed that IGFBP-4 proteolysis determined in both the presence and absence of exogenous IGF-II significantly increased during the first and second trimesters and reached a plateau by the third trimester. However, in the absence of IGF-II, IGFBP-4 proteolysis by pregnancy serum was only observed after prolonged incubation. IGF-II dose dependently increased IGFBP-4 proteolysis by pregnancy serum, with maximal stimulation observed at a concentration of 0.7 mol/L relative to IGFBP-4. In contrast, IGF-II at an equimolar dose had little effect on proteolysis of recombinant human IGFBP-3, whereas excess IGF-II reproducibly inhibited recombinant human IGFBP-3 proteolysis by pregnancy serum. Although IGF-II enhanced IGFBP-4 proteolysis, results from N-terminal sequence and mass spectrometric analyses of IGFBP-4 proteolytic fragments demonstrate that the cleavage site (Met135-Lys136) in human IGFBP-4 was not altered by IGF-II. Deletion of the residues 121-141 containing this cleavage site blocked IGFBP-4 proteolysis. These findings demonstrate that the increase in IGFBP-4 proteolysis during pregnancy was accounted for mainly by the IGF-II-dependent IGFBP-4 proteolysis. Because IGFBP-4 is a potent inhibitor of IGF actions, it can be speculated that the pregnancy-induced IGFBP-4 proteases may play an important role in regulating fetal growth.