Abstract PD6-07: Trends in the cost of care for breast cancer among women with commercial insurance

Background: Breast cancer care imposes a significant financial burden to U.S. healthcare systems and has become a key focus in the health care debate. Therapies for breast cancer are expensive, and the economic burden of these therapies may be rising due to the rapid introduction of pricey new drugs and techniques. There are limited data on the health care costs of individuals with breast cancer after initial diagnosis and how these costs have changed over time.

Methods: We conducted a retrospective analysis of commercially insured adult women with newly diagnosed non-metastatic breast cancer (identified via previously published claims-based algorithms) using 2007-2016 data from a large US health plan available in OptumLabs® Data Warehouse. We included patients with continuous health plan coverage for at least 2 years after initial diagnosis 2007-2014 and assessed how total health care spending and out-of-pocket costs (paid amounts) changed over this time. Costs were adjusted to 2016 US dollars using the general Consumer Price Index. Inpatient, outpatient, and outpatient pharmacy costs were evaluated. A multivariable logistic regression model was used to examine predictors of above average cost (cost > mean for that year of diagnosis).

Results: A total of 12,446 newly diagnosed breast cancer patients were identified (mean age, 51.6 years). Forty percent had undergone mastectomy, 38% chemotherapy, and 63% radiation. After adjustment for inflation, total healthcare costs increased 29.7% from 2007 to 2014 (Table 1), with increases primarily observed during the first year after diagnosis. Out-of-pocket costs remained relatively stable, and accounted for 5.3% of the total spending. Approximately 80% of the total costs were related to care received in the outpatient setting. Factors independently associated with above average spending included treatment with mastectomy [OR 1.78 (95% CI 1.5-2.1)], reconstruction [OR 3.0 (95% CI 2.6-3.5)], radiation [OR 4.0 (95% CI 3.4-4.7)] and chemotherapy [OR 18.4 (95% CI 16.6-20.3].

Table 1.Average healthcare spending over time Mean cost during first year after diagnosisMean cost during second year after diagnosisYear of diagnosistotalout-of-pockettotalout-of-pocket2007$80,296.17$4,271.25$16,559.21$1,907.012008$84,126.70$4,445.78$16,785.43$2,205.982009$88,331.45$4,728.42$17,005.68$2,214.932010$91,502.58$5,067.78$17,243.91$2,126.192011$93,826.40$5,089.45$16,862.45$2,027.962012$96,690.06$5,449.91$17,814.09$2,179.262013$104,064.93$5,678.19$17,087.47$2,115.972014$104,169.74$5,620.51$16,714.12$1,590.67

Conclusions: Breast cancer care is increasingly expensive during the first year after diagnosis, and costs are greatest for the recipients of more aggressive treatments. Costs during the second year after diagnosis have remained relatively stable.

Citation Format: Ruddy KJ, Sangaralingham LR, Freedman RA, Jemal A, Mougalian SS, Keegan T, Loprinzi CL, Gross CP, Henk HJ, Shah N. Trends in the cost of care for breast cancer among women with commercial insurance [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-07.

A spatial analysis of giardiasis and cryptosporidiosis in relation to public water supply distribution in North West England

Giardia and Cryptosporidium are both waterborne parasites and leading causes of gastroenteritis. Although specimens from diarrhoeic patients are routinely examined for Cryptosporidium, they are often not examined for Giardia so many cases go undiagnosed. Since 2002, all faecal specimens in Central Lancashire have been tested for infection with Giardia and Cryptosporidium. The aim of this paper is to gain insight into the factors contributing to giardiasis and cryptosporidiosis, including evidence of transmission via drinking water. Our analysis found a higher risk of both conditions for young children and a second peak in risk of giardiasis in adults. There was a significantly higher risk of giardiasis for males and a higher risk of cryptosporidiosis for females. The geographical location was significant, with an increased risk in the north. Residence in an area with increased supply from one water treatment works was a significant predictor for cryptosporidiosis.

Stevens-Johnson syndrome after Mycoplasma pneumonia infection in pediatric post-liver transplant recipient: case report and review of the literature

Although Mycoplasma pneumonia infection is relatively common among school-aged children, it rarely leads to SJS. Herein, we report a seven-yr-old girl who presented with a Mycoplasma pneumonia infection that progressed to SJS five months after liver transplant. We suggest that children presenting with symptoms of Mycoplasma pneumonia infection in the immunosuppressed post-liver transplant setting be properly diagnosed and treated rapidly, as well as observed for symptoms of SJS and potentially serious extrapulmonary complications.

Does hospital cleanliness correlate with meticillin-resistant Staphylococcus aureus bacteraemia rates?

Publicly available data for all National Health Service hospitals in England were used to examine whether there is a link between hospital cleanliness and rates of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia. It was not possible to demonstrate a consistent relationship between hospital cleanliness, as measured by weighted Patient Environment Action Team (PEAT) scores, and the incidence of MRSA bacteraemia. The large sizes of the data sets make it unlikely that a true correlation was missed. While a high standard of hospital cleanliness is a worthwhile goal, it is not helpful to repeatedly link MRSA control measures with improvements in standards of environmental cleanliness.

Assessment of environmental arsenic levels in Prievidza district

A coal-burning power station in the Nitra Valley in central Slovakia annually emitted large quantities of arsenic (up to 200 tonnes) between 1953 and 1989. Since then, pollution-control measures have reduced arsenic emissions to less than 2 tonnes a year. However, the power station was still a source of airborne arsenic pollution. As part of an EU-funded study on exposure to arsenic and cancer risk in central and Eastern Europe we carried out a study of environmental levels of arsenic in the homes and gardens of residents of the district. Garden soil samples (n=210), house dust samples (n=210) and composite house dust samples (n=109) were collected and analysed using inductively coupled plasma atomic absorption spectroscopy (ICP-AES) at Imperial College. The mean arsenic content of coal and ash in samples taken from the plant was 519 microg/g (n=19) and 863 microg/g (n=22), respectively. The geometric mean (GM) arsenic concentration of garden soils was 26 microg/g (range 8.8-139.0 microg/g), for house dust 11.6 microg/g (range 2.1-170 microg/g) and for composite house dust 9.4 microg/g (range 2.3-61.5 microg/g). The correlation between the arsenic levels in soil and in house dust was 0.3 (P<0.01), in soil and composite house dust 0.4 and house dust and composite house dust 0.4 (P<0.01 for both), i.e., were moderate. Arsenic levels in both house dust and soil decreased with distance from the power station. Overall, levels in both fell by half 5 km from the point source. Weak correlations were seen between the total urinary arsenic concentrations and arsenic concentrations in composite house dust.

Use of routinely collected data on trihalomethane in drinking water for epidemiological purposes

OBJECTIVES

To explore the use of routinely collected trihalomethane (THM) measurements for epidemiological studies. Recently there has been interest in the relation between byproducts of disinfection of public drinking water and certain adverse reproductive outcomes, including stillbirth, congenital malformations, and low birth weight.

METHOD

Five years of THM readings (1992--6), collected for compliance with statutory limits, were analysed. One water company in the north west of England, divided into 288 water zones, provided 15,984 observations for statistical analysis. On average each zone was sampled 11.1 times a year. Five year, annual, monthly, and seasonal variation in THMs were examined as well as the variability within and between zones.

RESULTS

Between 1992 and 1996 the total THM (TTHM) annual zone means were less than half the statutory concentration, at approximately 46 microg/l. Differences in annual water zone means were within 7%. Over the study period, the maximum water zone mean fell from 142.2 to 88.1 microg/l. Mean annual concentrations for individual THMs (microg/l) were 36.6, 8.0, and 2.8 for chloroform, bromodichloromethane (BDCM), and dibromochloromethane (DBCM) respectively. Bromoform data were not analysed, because a high proportion of the data were below the detection limit. The correlation between chloroform and TTHM was 0.98, between BDCM and TTHM 0.62, and between DBCM and TTHM -0.09. Between zone variation was larger than within zone variation for chloroform and BDCM, but not for DBCM. There was only little seasonal variation (<3%). Monthly variation was found although there were no consistent trends within years.

CONCLUSION

In an area where the TTHM concentrations were less than half the statutory limit (48 microg/l) chloroform formed a high proportion of TTHM. The results of the correlation analysis suggest that TTHM concentrations provided a good indication of chloroform concentrations, a reasonable indication of BDCM concentrations, but no indication of DBCM. Zone means were similar over the years, but the maximum concentrations reduced considerably, which suggests that successful improvements in treatment have been made to reduce high TTHM concentrations in the area. For chloroform and BDCM, the main THMs, the component between water zones was greater than variation within water zones and explained most of the overall exposure variation. Variation between months and seasons was low and showed no clear trends within years. The results indicate that routinely collected data can be used to obtain exposure estimates for epidemiological studies at a small area level.

Community Mothers Programme--seven year follow-up of a randomized controlled trial of non-professional intervention in parenting

BACKGROUND

The Community Mothers Programme aims at using experienced volunteer mothers in disadvantaged areas to give support to first-time parents in rearing their children up to 1 year of age. The programme was evaluated by randomized controlled trial in 1990.

METHODS

Seven years later, trial participants were interviewed about child health, nutrition, cognitive stimulation, parenting skills, and maternal self-esteem. The aim of this study was to see whether the demonstrated benefits at 1 year of age of this programme could be sustained at age 8.

RESULTS

One-third of the original group (38 intervention, 38 control), were contacted and interviewed. The risk for having an accident requiring a hospital visit was lower in the intervention group: relative risk (RR) 0.59, 95 per cent confidence interval (CI) 0.31-1.11. Intervention children were more likely to visit the library weekly: RR 1.58, 95 per cent CI 1.10-2.26. Intervention mothers were more likely to check homework every night: RR 1.23, 95 per cent CI 1.05-1.43 (p=0.006); and to disagree with the statement 'children should be smacked for persistently bad behaviour': RR 2.11, 95 per cent CI 1.10-4.06. They were more likely to disagree with the statement 'I do not have much to be proud of': RR 1.24, 95 per cent CI 1.04-1.40; and to make a positive statement about motherhood than controls: RR 1.53, 95 per cent CI 1.06-2.20. Subsequent children of intervention mothers were more likely to have completed Haemophilus influenzae b: RR 1.26, 95 per cent CI 1.06-1.51; and polio immunization: RR 1.19, 95 per cent CI 1.02-1.40.

CONCLUSIONS

The Community Mothers programme had sustained beneficial effects on parenting skills and maternal self-esteem 7 years later with benefit extending to subsequent children.

In vitro and in vivo evaluation of cotton wool filtration of platelet concentrates obtained by automated and manual apheresis

The effect of cotton wool filtration of apheresis platelet concentrates (PCs) on platelet viability and complement activation was evaluated by two laboratories. PCs were prepared by automated (Lab A, n = 5) or manual (Lab B, n = 5) apheresis. After storage for 1 day, the PC was filtered through cotton wool before transfusion on one occasion and, on the other occasion, filtered through a standard screen filter before transfusion to the same donor. Five paired studies were performed by each laboratory. Except for a small, but significant reduction in mean platelet size, from 7.3 +/- 1.1 to 6.6 +/- 0.9 microns 3, after cotton wool filtration, no effect of filtration on various tests of in vitro platelet function and morphologic integrity was found. As demonstrated by autologous radiolabeled studies, no effect of cotton wool filtration on platelet viability was found by Laboratory B, while Laboratory A found a slight increase in the percentage of recovery from 59 +/- 4 to 68 +/- 13 percent, and a small reduction in survival, from 8.2 +/- 0.9 to 7.7 +/- 0.5 days after cotton wool filtration (p less than 0.05). Cotton wool filtration was associated with a slight increase in C3a levels found in manual apheresis PCs. Neither laboratory found any effect of cotton wool filtration per se on the recipients' white cell (WBC) counts or C3a and C5a levels after transfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Paired comparison of platelet concentrates prepared from platelet-rich plasma and buffy coats using a new technique with 111In and 51Cr

Two techniques for the preparation of platelet concentrate (PC), the standard platelet-rich plasma (PRP) and buffy coat (BC) methods, were compared in nine paired studies with regard to platelet harvest, white cell (WBC) contamination, and PC quality after 5 days of 22 degrees C storage. Platelet harvest using the BC method averaged approximately 56 percent of the whole blood level (6.2 x 10(10)/concentrate), which was less than the 76 percent achieved with the PRP-PC method (8.7 x 10(10)/concentrate). An additional 5 units collected into an experimental siphon bag for BC-PC processing showed improved platelet harvest (6.7 x 10(10)/concentrate, or approx. 70% of whole blood). WBCs remaining in the BC-PC averaged 0.19 x 10(8) per unit compared to 3.6 x 10(8) per unit for PRP-PC. Buffy coat processing produced red cell (RBC) units with 50 percent of the WBC contamination of conventionally prepared units (9.8 +/- 6.2 x 10(8)/unit vs. 18.9 +/- 7.1 x 10(8)/unit). The siphon bag further reduced WBC levels in the AS-3 RBC units (6.4 +/- 3.7 x 10(8)/unit). In vitro studies performed on Days 1 and 5 after collection showed no significant differences in platelet metabolic and biologic function or cell integrity. Beta-thromboglobulin and surface glycoprotein levels, indicators of platelet activation and membrane alteration, respectively, did not differ significantly in the PRP-PC and BC-PC; nor was lactate production higher in PRP-PC, despite the substantially higher WBC counts. Autologous in vivo platelet viability determinations were performed by using concurrent transfusion of 111In-labeled freshly drawn platelets and 51Cr-labeled stored platelets.(ABSTRACT TRUNCATED AT 250 WORDS)

Refrigerated storage of washed red cells

Red cells washed and stored in a citrate-phosphate-glucose-adenine solution at pH 7.4-7.6 demonstrate excellent maintenance of adenosine triphosphate, elevation of 2,3-diphosphoglycerate well above normal levels for more than 6 weeks, reduced hemolysis and 24-hour in vivo survival comparable to that of cells stored in ADSOL. These results can be attributed in part to a chloride shift in which the washout of intracellular chloride is associated with an influx of OH-, which increases intracellular pH and thereby increases the rate of glycolysis. The phosphate functions primarily as a buffer to maintain both extra- and intracellular pH. Reducing the effective osmolality of the storage solution reduces hemolysis and improves cell morphology.

Storage of ADSOL-preserved red cells at 2.5 and 5.5 degrees C: comparable retention of in vitro properties

Previous studies with CPDA-1 and Nutricel preserving solutions indicated that red cell properties were affected by small differences in storage temperature. The influence of a 3 degrees C differential on the preservation of the in vitro properties of ADSOL-preserved (AS-1) red blood cells was investigated in a paired study. AS-1 red blood cells were stored at 2.5 and 5.5 degrees C for 42 days. Extent of hemolysis, glucose consumption and pH levels were comparable at the two storage temperatures. Lactate levels were slightly, but significantly higher at 5.5 degrees C. ATP levels were slightly but significantly higher at 2.5 degrees C, only during the later part of the storage period. 2.3-DPG levels were slightly better retained at 2.5 degrees C after 7 days of storage. Holding units of whole blood for either 1 or 8 h at ambient temperature after phlebotomy prior to processing did not influence the types of temperature-dependent changes. The differences as a function of storage temperature were small and appear to be of no practical importance in connection with the storage of AS-1 red blood cells.

Development of a combined storage medium for 7-day storage of platelet concentrates and 42-day storage of red cell concentrates

Studies were carried out to examine whether a single additive solution could support both platelet and red cell storage. An ionically balanced electrolyte solution fortified with citrate, glucose and bicarbonate was used. This solution has previously been shown to provide good platelet viability with storage for up to 7 d. Optimization studies demonstrated that with adenine added to this solution (CSM), it also allowed for satisfactory preservation of in vitro red cell parameters for up to 49 d of storage. Confirmatory paired in vivo post-transfusion studies were carried out in which platelets and red cells obtained from the same donor were processed and stored in CSM on one occasion, and in CPD-plasma (platelets) and AS-1 (red cells) on another occasion. Five paired studies were conducted with platelets stored for 5 d and red cells for 42 d; another five paired studies with platelets stored for 7 d and red cells for 49 d. Except for a slight decrease in platelet survival (P less than 0.05) with storage in CSM, there were no statistically significant differences in post-transfusion recoveries and survivals between test and control media, demonstrating that both platelets and red cells may be satisfactorily stored in a combined single additive solution.

Studies with nonradioisotopic sodium chromate. II. Single- and double-label 52Cr/51Cr posttransfusion recovery estimations

A recently developed nonradioisotopic 52Cr technique was used to measure either red cell volume or posttransfusion recovery of stored red cells. The experimental method uses Zeeman electrothermal atomic absorption spectrophotometry to measure red cell chromium. Results from the 52Cr method were compared with those from 51Cr single-label and 125I-albumin/51Cr double-label procedures using 49-day AS-1 red cell concentrates drawn and prepared according to standard procedures. In the first group of five donors, red cell volume was estimated concurrently with both 52Cr-labeled fresh red cells and 125I-albumin. The latter measured plasma volume from which red cell volume was estimated on the basis of the hematocrit (125I red cell volume). 51Cr-labeled stored red cells were transfused to measure posttransfusion recoveries. The correlation between 52Cr and 125I red cell volumes was significant (r = 0.68, p less than 0.01), and, in this group, the differences were not significant (p less than 0.05). Twenty-four-hour posttransfusion recoveries of 51Cr-labeled stored red cells averaged 66 +/- 5 percent when measured with the 125I/51Cr technique and 69 +/- 8 percent when measured with the 52Cr/51Cr method. In the second group of five donors, red cell volume was estimated by the 125I-albumin technique, and the posttransfusion recovery of stored red cells was quantitated by 51Cr- and 52Cr-labeled stored cells simultaneously. In this group, posttransfusion recoveries with 125I/51Cr averaged 73 +/- 7 percent; with 125I/52Cr, they averaged 75 +/- 10 percent. Using the single-label method of calculation, recoveries averaged 76 +/- 7 and 75 +/- 10 percent for the 51Cr and 52Cr methods, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of 99mtechnetium/51chromium post-transfusion recovery of red cells stored in saline, adenine, glucose, mannitol for 42 days

An in vivo and in vitro study of 42-day saline, adenine, glucose, mannitol (SAGM) red cells (Terumo Corporation, Elkton, Md.) was conducted using 20 volunteers to document in vivo efficacy and analyze the validity of the 99mTc/51Cr technique. In vivo autologous post-transfusion recovery was measured by a double-label procedure involving the use of 99mTc-labeled freshly drawn red cells to quantify recipient blood volume and 51Cr to document both post-transfusion 24-hour recovery (PTR) and red cell survival. As an internal control, 5 of the 20 donors studied had red cell volumes estimated by the 125I-albumin (RISA) plasma volume technique on a separate occasion. For comparison, PTR was also calculated according to the single-label 51Cr protocol in which recipient blood volume was estimated by extrapolation from circulating 51Cr-labeled red cell activity 5-15 min after infusion. After 42 days of storage, PTR averaged 78 +/- 6% with the double-label 99mTc/51Cr technique and 81 +/- 5% with the single-label (51Cr alone), confirming a small difference between the two techniques. Correlation between the two techniques was high, r = 0.81, though the average 3% difference between them was significant (p less than 0.05). Red cell volumes of the 5 donors measured by both the 99mTc-red cell method and the 125I-albumin method exhibited excellent correlation, r = 0.96, and averaged 1,961 +/- 420 ml and 2,048 +/- 381 ml, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo regeneration of red cell 2,3-diphosphoglycerate following transfusion of DPG-depleted AS-1, AS-3 and CPDA-1 red cells

Regeneration of 2,3-diphosphoglycerate (DPG) was determined following transfusion of DPG-depleted group O red cells into group A recipients. Blood from five donors was stored in the adenine-containing solutions CPDA-1, AS-1 or AS-3 for 35 d at 4 degrees C. Post-transfusion red cell DPG and ATP were measured in separated group O red cells over a 7 d period. The studies confirmed rapid in vivo DPG regeneration with greater than or equal to 50% of the maximum level being achieved within 7 h. An average of 95% of the recipients' pre-transfusion DPG level was achieved by 72 h and by 7 d mean (+/- SEM) DPG levels relative to recipient's pre-transfusion DPG averaged 84% (+/- 13%), 92% (+/- 17%) and 84% (+/- 21%) for CPDA-1, AS-1 and AS-3 red cells, respectively. Results were comparable to those previously reported for blood stored in ACD for 15-20 d (Valeri & Hirsch, 1969; Beutler & Wood, 1969). The immediate regeneration rate, V, closely approximated first order regeneration kinetics with AS-3 red cells exhibiting double the rate of CPDA-1 red cells (P less than 0.001). AS-1 red cells exhibited an intermediate rate of regeneration which was not significantly different compared to either CPDA-1 or AS-3 (P greater than 0.05). V exhibited a significant (P less than 0.05) positive correlation with ATP levels 5-7 h post-infusion. ATP regeneration of the infused cells was rapid with a mean increase of 1.2 mumol/g Hb above post-storage levels being achieved 1 h following transfusion.