Objective performance measures using motion sensors on an endoscopic tool for evaluating skills in natural orifice translumenal endoscopic surgery (NOTES).

Natural orifice translumenal endoscopic surgery is an emerging procedure. High fidelity virtual reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing a Virtual Transluminal Endoscopic Surgery Trainer (VTEST TM) for this purpose. In this work, objective performance measures derived from motion tracking sensors attached to an endoscope was tested for the transgastric NOTES appendectomy procedure performed with ex-vivo pig organs using the EASIE-R(TM) trainer box. Results from our study shows that both completion time and economy of motion parameters were able to differentiate between expert and novice NOTES surgeons with p value of 0.039 and 0.02 respectively. Jerk computed on sensor 2 data also showed significant results (p = 0.02). We plan to incorporate these objective performance measures in VTEST(TM).

Economic Burden of Metastatic Ovarian Cancer in a Commercially Insured Population: A Retrospective Cohort Analysis.

BACKGROUND: Ovarian cancer is the tenth most common type of cancer and the fifth leading cause of cancer death among females in the United States. The majority of incident ovarian cancer cases are diagnosed in individuals aged < 65 years, but limited evidence exists regarding the economic burden of ovarian cancer in this age group. OBJECTIVES: To (a) estimate the annual all-cause direct total cost of metastatic ovarian cancer and (b) compare it to the cost of individuals without cancer in the working age commercially insured U.S. METHODS: We conducted a retrospective cohort analysis using the IBM MarketScan Commercial Database. Patients were included if they met the following criteria: ≥ 1 medical claim with a secondary malignancy diagnosis in the primary position between January 1, 2011, and December 31, 2015 (earliest date of diagnosis defined as the index date); aged ≥ 18 years on the index date; ≥ 12 months of continuous enrollment before the index date; ≥ 1 month of continuous enrollment after the index date; and ≥ 1 inpatient medical claim or ≥ 2 outpatient medical claims ≥ 30 days apart, with an ovarian cancer diagnosis in any claim position within 60 days before or 30 days after the index date. Patients were excluded if they had ≥ 1 medical claim with a cancer diagnosis except for ovarian cancer in any claim position during the 12-month pre-index period. Controls were randomly selected and matched to metastatic ovarian cancer patients based on age, region, index date, number of months of continuous enrollment after the index date, and propensity score. Annual all-cause direct total costs and ovarian cancer-related direct total costs were estimated and compared for each cohort by using the Kaplan-Meier sample average technique to account for censoring after the index date. RESULTS: 2,991 metastatic ovarian cancer patients and 2,991 matched controls were included in this study. Patients in the metastatic ovarian cancer cohort had a mean (SD) age of 54.4 (8.5) years, and controls had a mean (SD) age of 54.2 (8.4) years. The mean (95% CI) annual all-cause total costs in the 12-month post-index period were $140,124 ($134,025-$146,267) for metastatic ovarian cancer patients and $35,161 ($31,338-$39,529) for controls; the resulting mean (95% CI) difference in annual all-cause total costs was $104,964 ($99,732-$110,042). In comparison with the annual all-cause total costs, the mean (95% CI) annual ovarian cancer-related total costs in the 12-month post-index period were $86,971 ($82,349-$91,508) for metastatic ovarian cancer patients and $0 ($0-$0) for controls. CONCLUSIONS: Working age patients with metastatic ovarian cancer have significantly higher costs compared with those without cancer. These findings contribute to the understanding of the burden of illness in a patient population where limited evidence currently exists on the economic consequences of the disease. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. This study was presented at the 2019 International Society for Pharmacoeconomics and Outcomes Research Annual Meeting; May 18-22, 2019; New Orleans, LA.

Performance-Based Risk-Sharing Arrangements for Pharmaceutical Products in the United States: A Systematic Review.

BACKGROUND: Value for money is a growing necessity in today's U.S. health care system in which drug spending is expected to increase by an average rate of 6.7% yearly through 2025. In response to uncertainty about real-world clinical and economic outcomes for many drugs, health insurers and pharmacy benefit managers (PBMs) have implemented various contracts and arrangements with drug manufacturers that can collectively be described as performance-based risk-sharing arrangements (PBRSAs). Little is known about U.S.-specific PBRSAs for drugs. OBJECTIVES: To conduct a systematic review of U.S.-specific PBRSAs for drugs to describe (a) trends over time and (b) key aspects including outcome measures and terms of arrangements between stakeholders. METHODS: A systematic review was conducted in MEDLINE (January 1, 1946-April 1, 2017), Embase (January 1, 1988-April 1, 2017), and the grey literature (up to April 1, 2017) to identify publicly disclosed PBRSAs. Articles and conference abstracts were included if they were published in English and described a U.S.-specific PBRSA for a drug. Articles and conference abstracts were excluded if they only described a PBRSA similar to a money-back guarantee to patients. They were also excluded if they only described a PBRSA between a PBM and a health insurer in which the latter would receive a discount for patients nonadherent to a drug. Results were summarized as counts and percentages. RESULTS: From the literature review, 26 publicly disclosed PBRSAs were identified. Of these, 16 (62%) were announced or initiated from 2015 to 2017, and 10 (38%) were announced or initiated from 1997 to 2012. Thirteen (50%) PBRSAs involved cardiometabolic indications; 5 (19%) involved oncology indications; and 8 (31%) involved other indications. Categorized by health insurer or PBM, 10 (38%) PBRSAs involved large multistate insurers; 5 (19%) involved the Centers for Medicare & Medicaid Services; 7 (27%) involved regional insurers; 3 (12%) involved PBMs; and 1 (4%) involved multiple unspecified insurers. Regarding the most active drug manufacturers, Amgen initiated 5 (19%) PBRSAs and Novartis initiated 4 (15%). Relative to the initial FDA approval of a treatment, 15 (58%) PBRSAs were announced or initiated within 5 years, and 11 (42%) were announced or initiated more than 5 years later. For data collection, electronic medical record (EMR) data would have been an appropriate source for 12 (46%) PBRSAs; claims data would have been an appropriate source for 11 (42%) PBRSAs; and EMR and claims data would have been appropriate sources for 2 (8%) PBRSAs; no description of the outcome measures was available for 1 (4%) PBRSA. CONCLUSIONS: The number of publicly disclosed U.S.-specific PBRSAs for drugs has increased over the years. This review's findings confirm the interest of stakeholders in such arrangements and their confidence in the use of the selected outcome measures. Each PBRSA represents a timely collaboration among stakeholders to provide access to a drug while generating evidence to better elucidate its clinical and economic value. DISCLOSURES: No funding supported this systematic review. Yu is an employee and shareholder of Allergan. Chin reports personal fees from Formulary Resources. Oh and Farias have nothing to disclose. Study concept and design were primarily contributed by Yu, along with the other authors. All authors contributed to the collection and interpretation of the data. The manuscript was written by Yu, Chin, Oh, and Farias and revised by Yu and Chin, along with the other authors.

Characterizing the Strength of Evidence in FDA Labels for Pharmacogenomic Biomarker-Guided Medication Use.

There is great heterogeneity in drug treatment response that is thought to be due to individual-level allelic variation in pharmacogenomic biomarkers. FDA Drug Labels provide information to guide pharmacogenomic biomarker use. Yet, the strength of evidence for clinical validity and clinical utility is lacking. We characterized the strength of evidence and treatment recommendations contained in FDA Drug Labels as of December 2015. Pharmacogenomic biomarker information was provided for 137 drugs, involving 49 pharmacogenomic biomarkers, constituting 166 drug-biomarker pairs. Convincing/adequate evidence of clinical validity was found for 46% of pairs, of clinical utility for 29% of pairs, and of both, for 27% of pairs. Despite evidence of convincing/adequate validity/utility, no treatment recommendation was provided for 37% of pairs. Germline biomarkers represented nearly three-quarters of all drug-biomarker pairs, however, only 29% and 16% of pairs had convincing/adequate evidence for clinical validity and clinical utility, respectively. Separately, somatic biomarkers that serve as molecular targets for targeted therapies, had convincing/adequate evidence for 95% of pairs for clinical validity, and for 67% for clinical utility. The strength of evidence for pharmacogenomic biomarker use is low, underscoring the need for additional research to achieve the promise of precision medicine.