Assessing the transition from intravenous to subcutaneous delivery of rituximab: Benefits for payers, health care professionals, and patients with lymphoma.

Subcutaneous (SC) administration of rituximab provides an opportunity for reduced patient treatment burden and increased healthcare efficiencies as an alternative to intravenous (IV) rituximab. There is minimal evidence comparing costs associated with SC and IV rituximab in a US setting. This research assessed the impact of transitioning patients from IV to SC rituximab for treatment of non-Hodgkin's lymphoma (NHL) from the US payer, provider, and patient perspective. We developed a model to estimate cost differences for transitioning 20% of a patient cohort from IV to SC rituximab. We included patients with incident diffuse large B-cell lymphoma, incident and recurrent follicular lymphoma, and incident and recurrent chronic lymphocytic leukemia. In the model, each patient received the same number of doses and that there was no difference in discontinuation between cohorts due to non-inferior efficacy and a similar safety profile. Model inputs were collected from published literature and publicly available data. Scenario analyses tested the impact of availability of low-cost biosimilars. In the base case (1,000,000 covered lives), we estimated a total of 157 patients, with 769 total drug administrations. A transition of 20% of patients from IV to SC was projected to generate $153,000 in payer savings, increase provider capacity by 270 hours, and free 470 hours of patient time. Scenario analyses suggest SC administration will be cost saving for payers even with a market where biosimilars approach 50% market share. A 20% transition to SC rituximab in a single cohort of patients has the potential to generate significant US health system value in the form of payer savings, increased practice capacity, and patient time.

Intravenous and subcutaneous formulations of trastuzumab, and trastuzumab biosimilars: implications for clinical practice.

Trastuzumab is a biologic therapy indicated for the treatment of human epidermal growth factor receptor 2 (HER2)-positive breast cancer and metastatic gastric cancer. Trastuzumab was originally approved as an intravenous (IV) formulation but has since been developed for subcutaneous (SC) administration for patients with HER2-positive breast cancer. Both formulations demonstrate generally comparable pharmacological and clinical profiles. Therefore, when deciding between treatment options, factors such as the route of administration, patient preference, value and cost must be considered. Studies comparing IV with SC trastuzumab indicate that each formulation offers unique advantages to patients depending on their individual needs. Concurrent with the development of SC trastuzumab, IV trastuzumab biosimilars comprise another treatment option that, in view of their reduced cost, might improve patient access and increase cost-effectiveness for healthcare providers and payers. In this review, we seek to raise awareness of the current options available for trastuzumab so that healthcare providers can optimally treat patients according to their individual situations and preferences.

Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial.

OBJECTIVES: In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT. METHODS: This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC. RESULTS: Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006). CONCLUSIONS: LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT.

A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol.

Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0-2 h (734 participants), 2-6 h (766 participants), 6-24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of -0.17 (-0.45 to 0.10), -0.09 (-0.24 to 0.06), 0.06 (-0.12 to 0.23) and 0.03 (-0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0-2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.

Clinical and pharmacoeconomic evaluation of antifungal prophylaxis with continuous micafungin in patients undergoing allogeneic stem cell transplantation: A six-year cohort analysis.

BACKGROUND: Patients undergoing allogeneic stem cell transplantation (aSCT) are at high risk to develop an invasive fungal disease (IFD). Optimisation of antifungal prophylaxis strategies may improve patient outcomes and reduce treatment costs. OBJECTIVES: To analyse the clinical and economical impact of using continuous micafungin as antifungal prophylaxis. PATIENTS/METHODS: We performed a single-centre evaluation comparing patients who received either oral posaconazole with micafungin as intravenous bridging as required (POS-MIC) to patients who received only micafungin (MIC) as antifungal prophylaxis after aSCT. Epidemiological, clinical and direct treatment cost data extracted from the Cologne Cohort of Neutropenic Patients (CoCoNut) were analysed. RESULTS: Three hundred and thirteen patients (97 and 216 patients in the POS-MIC and MIC groups, respectively) were included into the analysis. In the POS-MIC and MIC groups, median overall length of stay was 42 days (IQR: 35-52 days) vs 40 days (IQR: 35-49 days; p = .296), resulting in median overall costs of €42,964 (IQR: €35,040-€56,348) vs €43,291 (IQR: €37,281 vs €51,848; p = .993), respectively. Probable/proven IFD in the POS-MIC and MIC groups occurred in 5 patients (5%) vs 3 patients (1%; p = .051), respectively. The Kaplan-Meier analysis showed improved outcome of patients in the MIC group at day 100 (p = .037) and day 365 (p < .001) following aSCT. CONCLUSIONS: Our study results demonstrate improved outcomes in the MIC group compared with the POS-MIC group, which can in part be explained by a tendency towards less probable/proven IFD. Higher drug acquisition costs of micafungin did not translate into higher overall costs.

Primary immunodeficiency disease: a cost-utility analysis comparing intravenous vs subcutaneous immunoglobulin replacement therapy in Australia.

BACKGROUND: Hospital-based intravenous immunoglobulin (IVIg) treatment has been the standard treatment mode for patients with primary immunodeficiency disease (PID). With the newer home-based subcutaneous immunoglobulin (SCIg) becoming approved for use in most countries, the question arises as to whether SCIg is a cost-effective treatment mode compared to IVIg in Australia. MATERIALS AND METHODS: We developed a Markov cohort simulation model with six health states: PID without infection, PID with infection treated at home or hospital, bronchiectasis without infection, bronchiectasis with infection treated at home or hospital, bronchiectasis with chronic Pseudomonas aeruginosa infection, and death, from an Australian healthcare system perspective. A 10-year time horizon with weekly cycles was chosen, and the expected costs and quality-adjusted life-years (QALYs) of the two treatment options estimated. RESULTS: The cumulative 10-year cost per patient was 297,547 Australian dollars (A$) with IVIg and A$ 251,713 for SCIg. IVIg resulted in 5.55 QALYs and SCIg 5.57 QALYs. Thus, SCIg appears to be a cost-saving option and possibly improves QALY from the Australian healthcare system perspective (i.e., the dominant treatment option). A probabilistic sensitivity analysis showed that the SCIg option is preferred in 93.2% of simulations given willingness to pay of A$ 50,000 per QALY gained. DISCUSSION: The results suggest that home-based SCIg is a cost-effective treatment option for patients with PID in Queensland, Australia.

A micro-costing study: comparing a standard intravenous patient-controlled analgesia system with a novel sublingual patient-controlled analgesia system.

BACKGROUND: Judicious spending in healthcare is of paramount importance, particularly when introducing new devices or interventions. These products or interventions need to be economically efficient both directly and indirectly. An accepted method of cost estimation is micro-costing. Micro-costing involves direct enumeration and costing of every input consumed in the treatment of a particular patient when using new device, medicine or intervention. In our study, we investigated the cost of using a novel sublingual (SL) patient-controlled analgesia (PCA) device and compared it with our conventional intravenous (IV) PCA device. METHODS: A previous study performed in our institution produced a cost per use of IV PCA device at €97. This compared with a previous European study published in this journal in 2010 which showed a similar figure of €96 per use of IV PCA device. In our comparative study, we used a case record form (CRF) to incorporate a cost to all consumables used, staff time and equipment used to both the SL PCA and the IV PCA. RESULTS: A total of 60 patients of similar demographic were included in our study. The cost of an IV PCA episode was €97.89 and €182.32 for an SL PCA episode. Standl et al. (2010) showed that the average cost of an IV PCA episode was €96.40 with 78% of this being made up of staff time. SL PCA was more efficacious in certain patient groups and in certain surgical groups. CONCLUSION: After performance of a micro-costing study, the less costly IV PCA episode was statistically significant compared with a SL PCA episode. However, the associated staff costs were less with a SL PCA episode. We performed a micro-costing study on a novel sublingual PCA device and compared it with a conventional intravenous PCA device. All resources were included and compared.

Incidence and prevalence of intravenous medication errors in the UK: a systematic review.

Objectives: Medication error is the most common type of medical error, and intravenous medicines are at a higher risk as they are complex to prepare and administer. The WHO advocates a 50% reduction of harmful medication errors by 2022, but there is a lack of data in the UK that accurately estimates the true rate of intravenous medication errors. This study aimed to estimate the number of intravenous medication errors per 1000 administrations in the UK National Health Service and their associated economic costs. The rate of errors in prescribing, preparation and administration, and rate of different types of errors were also extracted. Methods: MEDLINE, Embase, Cochrane central register of clinical trials, Database of Abstracts of Reviews of Effectiveness, National Health Service Economic Evaluation Database and the Health Technology Appraisals Database were searched from inception to July 2017. Epidemiological studies to determine the incidence of intravenous medication errors set wholly or in part in the UK were included. 228 studies were identified, and after screening, eight papers were included, presenting 2576 infusions. Data were reviewed and extracted by a team of five reviewers with discrepancies in data extraction agreed by consensus. Results: Five of eight studies used a comparable denominator, and these data were pooled to determine a weighted mean incidence of 101 intravenous medication errors per 1000 administrations (95% CI 84 to 121). Three studies presented prevalence data but these were based on spontaneous reports only; therefore it did not support a true estimate. 32.1% (95% CI 30.6% to 33.7%) of intravenous medication errors were administration errors and 'wrong rate' errors accounted for 57.9% (95% CI 54.7% to 61.1%) of these. Conclusion: Intravenous medication errors in the UK are common, with half these of errors related to medication administration. National strategies are aimed at mitigating errors in prescribing and preparation. It is now time to focus on reducing administration error, particularly wrong rate errors.

Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs.

BACKGROUND: Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED. MATERIAL AND METHODS: We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226). RESULTS: In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively. DISCUSSION: The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

Improving the use of intravenous antihypertensive medications in the hospital setting: a quality improvement initiative for patient safety.

Intravenous (IV) hydralazine, enalapril and labetalol are oftentimes used without indication for the treatment of asymptomatic hypertension in the hospital setting and have been shown to have substantial adverse effects that are associated with increased morbidity and mortality, as well as longer length of stay. Their use is also associated with greater monetary costs. In this project, we studied the frequency of use and consequences of these medications before and after a series of education cycles which clarified when and when not to use intravenous antihypertensives (IVAHs). Our initial aim was to decrease the unindicated use of IVAH by at least 25% in the setting of asymptomatic hypertension in our community hospital within a 1-year period after introducing education on the topic. Multidisciplinary involvement throughout three Plan-Do-Study-Act (PDSA) cycles yielded favourable results. We focused on education towards a hospital-wide knowledge gap stemming from a lack of guidelines regarding the treatment of asymptomatic hypertension, as well as the guideline indications for IVAH. After three cycles of education targeting different groups, the unindicated use of IVAH fell by a total of 66%, decreasing patient exposure by approximately 248 cases over the total course of the study and ultimately, yielding a 52% increase in patient safety. Secondary outcome included a reduction in cost. It was noted that IV drugs cost more than their oral counterparts. The culture change in switching away from IVAH unless otherwise indicated was driven by repetitive education and group discussion to close the gap created by a lack of guidelines.

Intravenous versus subcutaneous trastuzumab: an economic and patient perspective.

Since 2005, when the first patients outside of a clinical trial were treated with trastuzumab at The Christie NHS Foundation Trust, a nurse-led service has been developed to facilitate and support a safe treatment pathway for patients. There have been significant developments in the number of patients treated, the mode of administration of the drug and patient choice regarding the location of treatment delivery. This article focuses on the change from intravenous to subcutaneous administration, considering patient experience and choice, particularly in light of the advent of biosimilar drugs, which will necessitate a return to the intravenous route. The relative costs of intravenous and subcutaneous administration are illustrated and the results of a patient survey presented, indicating a strong preference for subcutaneous trastuzumab.

A Cost Minimization Analysis of Ready-to-Administer Prefilled Sterilized Syringes in a Dutch Hospital.

PURPOSE: Preparation errors occur frequently during conventional preparation of parenteral medication in the clinical environment, causing patient harm and costs for the national health care system. The use of ready-to-administer prefilled sterilized syringes (PFSSs) produced by the hospital pharmacy can reduce preparation errors and the risk of bacteremia from contamination of the intravenous medication. The aim of this research is to compare the total costs of the conventional preparation method (CPM) with the PFSS method. METHODS: In this cost-minimization analysis, costs related to the preparation of the medication, bacteremia from contamination, adverse drug events as a result of preparation medication errors, and wastage of syringes were taken into account. Annual costs in a general Dutch hospital were consistently calculated. Three scenarios were analyzed: (1) all preparations as CPM (864,246 administrations per year), (2) all preparations as PFSSs, and (3) 50% as PFSSs and 50% as CPM. Deterministic and probabilistic sensitivity analyses were performed. FINDINGS: The first scenario found higher annual costs at €14.0 million (US$16.0 million) compared with the second scenario (€4.1 million, US$4.7 million). The most realistic situation (third scenario) found savings of €4.9 million (US$5.6 million) compared with the first scenario. Sensitivity analyses revealed that cost savings of PFSSs were strongly influenced by decreased risk of medication errors and contamination of intravenous medication. Extrapolating these results nationwide indicated potential savings of >€300 million (US$342 million) if only PFSSs were used. IMPLICATIONS: The use of PFSSs prepared in the hospital pharmacy yielded cost savings compared with the CPM on the ward in the Dutch hospital.

Cost Minimization Analysis of Intravenous or Subcutaneous Trastuzumab Treatment in Patients With HER2-Positive Breast Cancer in Ireland.

BACKGROUND: Two large acute Irish University teaching hospitals changed the manner in which they treated human epidermal growth factor receptor (HER)2-positive breast cancer patients by implementing the administration of trastuzumab via the subcutaneous (SC) route into their clinical practice. The study objective is to compare the trastuzumab SC and trastuzuamb intravenous (IV) treatment pathways in both hospitals and assess which route is more cost-effective and time saving in relation to active health care professional (HCP) time. MATERIALS AND METHODS: A prospective observational study in the form of cost minimization analysis constituted the study design. Active HCP time for trastuzumab SC- and IV-related tasks were recorded. Staff costs were calculated using fully loaded salary costs. Loss of productivity costs for patients were calculated using the human capital method. RESULTS: On average, the total HCP time saved per trastuzumab SC treatment cycle relative to trastuzumab IV treatment cycle was 59.21 minutes. Time savings in favor of trastuzumab SC resulted from quicker drug reconstitution, no IV catheter installation/removal, and less HCP monitoring. Over a full treatment course of 17 cycles, average HCP time saved accumulates to 16.78 hours, with an estimated direct cost saving of €1609.99. Loss of productivity for patients receiving trastuzumab IV (2.15 days) was greater than that of trastuzumab SC (0.60 days) for a full treatment course. CONCLUSION: Trastuzumab SC treatment has proven to be a more cost-effective option than trastuzumab IV treatment that generated greater HCP time savings in both study sites. Healthcare policymakers should consider replacing trastuzumab IV with trastuzumab SC treatment in all eligible patients.

Effects of Hospital Practice Patterns for Antibiotic Administration for Pneumonia on Hospital Lengths of Stay and Costs.

BACKGROUND: Hospital practice patterns vary for switching from intravenous to oral antibiotics for community-acquired pneumonia in pediatric patients, but it is unknown how these practice patterns affect hospital lengths of stay and costs. METHODS: We conducted a retrospective study of 78673 pediatric patients (aged 3 months to 17 years) hospitalized for community-acquired pneumonia. Analyses were performed with data from the Pediatric Health Information System between 2007 and 2016, including discharge data from 48 freestanding children's hospitals. Patients who received antibiotics used to treat aspiration pneumonia and patients with a complex chronic condition were excluded to focus the study on uncomplicated cases. We modeled hospital practice patterns using hospital-level averages for the last day of service on which patients received antibiotics intravenously or first day of service on which patients received antibiotics orally. RESULTS: We found that a 1-day decrease in the hospital-level average last day of service on which a patient received antibiotics intravenously reduced the average length of stay by 0.58 day (95% confidence interval [CI], -0.69 to -0.47 day) and average cost by $1332 (95% CI, -$2363 to -$300). Results were similar when hospital practice patterns were modeled using the average first day of service on which a patient received antibiotics orally. These reductions in lengths of stay and costs were not associated with a difference in 30-day readmission rates. CONCLUSIONS: Given the reductions in lengths of stay and costs without sacrificing patient outcomes (readmissions), antimicrobial stewardship programs could target provider education on the duration of intravenous antibiotic therapy as a way to reduce resource utilization.

Use of clinical decision support to identify i.v.-to-oral conversion opportunities and cost savings.

PURPOSE: The use of a clinical decision support (CDS) tool to determine patients' eligibility for oral medication therapy and the opportunity cost of i.v.-to-oral conversion practices in a large health system was evaluated. METHODS: This multicenter, retrospective, process improvement study comprised CDS data generated by 149 hospitals from May 1 through October 31, 2015. Data related to i.v.-to-oral conversions were identified and compiled for evaluation. For each patient with an opportunity for i.v.-to-oral therapy conversion, corresponding barcode-assisted medication administration data were evaluated to determine the number of doses that were administered within prespecified time periods. RESULTS: A total of 121,685 i.v.-to-oral conversion opportunities, corresponding to 71,342 unique patients and encompassing 31 different medications, were evaluated. The top 13 medications representing 94% of the total number of alerts and over 1.4 million doses were included for analysis. Current i.v.-to-oral conversion practices saved the hospitals 9% on medication costs. Upon further evaluation, additional cost savings of 29-78% for those 13 medications could be achieved with more timely conversion from i.v. to oral therapy. CONCLUSION: Hospital pharmacists' i.v.-to-oral conversion practices with the CDS tool resulted in medication cost savings of 9%, or $1.48 million, for 13 medications evaluated over a 6-month period.

Subcutaneous Administration of Biotherapeutics: An Overview of Current Challenges and Opportunities.

Subcutaneous delivery of biotherapeutics has become a valuable alternative to intravenous administration across many disease areas. Although the pharmacokinetic profiles of subcutaneous and intravenous formulations differ, subcutaneous administration has proven effective, safe, well-tolerated, generally preferred by patients and healthcare providers and to result in reduced drug delivery-related healthcare costs and resource use. The aim of this article is to discuss the differences between subcutaneous and intravenous dosing from both health-economic and scientific perspectives. The article covers different indications, treatment settings, administration volumes, and injection devices. We focus on biotherapeutics in rheumatoid arthritis (RA), immunoglobulin-replacement therapy in primary immunodeficiency (PI), beta interferons in multiple sclerosis (MS), and monoclonal antibodies (mAbs) in oncology. While most subcutaneous biotherapeutics in RA, PI, and MS are self-administered at home, mAbs for oncology are still only approved for administration in a healthcare setting. Beside concerns around the safety of biotherapeutics in oncology, a key challenge for self-administration in this area is that doses and dosing volumes can be comparatively large; however, this difficulty has recently been overcome to some extent by the development of high-concentration solutions, the use of infusion pumps, and the coadministration of the dispersion enhancer hyaluronidase. Furthermore, given the increasing number of biotherapeutics being considered for combination therapy and the high dosing complexity associated with these, especially when administered intravenously, subcutaneous delivery of fixed-dose combinations might be an alternative that will diminish these burdens on healthcare systems.

Applying Lean Techniques to Reduce Intravenous Waste Through Premixed Solutions and Increasing Production Frequency.

BACKGROUND: This study aims to use lean techniques and evaluate the impact of increasing the use of premixed IV solutions and increased IV production frequency on IV waste. METHODS: Study was conducted at a tertiary hospital pharmacy department in three phases. Phase I included evaluation of IV waste when IV production occurred three times a day and eight premixed IV products were used. Phase II increased the number of premixed IV products to 16. Phase III then increased IV production to five times a day. RESULTS: During Phase I, an estimate of 2,673 IV doses were wasted monthly, accounting for 6.14% of overall IV doses. This accounted for 688 L that cost $60,135. During Phase II, the average monthly IV wastage reduced significantly to 1,069 doses (2.84%), accounting for 447 L and $34,003. During Phase III, the average monthly IV wastage was further decreased to 675 doses (1.69%), accounting for 78 L and $3,431. Hence, a potential annual saving of $449,208 could result from these changes. CONCLUSION: IV waste was reduced through the increased use of premixed solutions and increasing IV production frequency.

Doctors' views of patient expectations of medical care in Zhejiang Province, China.

OBJECTIVE: Physicians' prescribing patterns may be influenced by how they perceive their patients' expectations of medical care. This study explored doctors' perceptions of patient expectations of medical care. DESIGN: Qualitative interviews and a cross-sectional survey (September 2014-September 2015). SETTING: Primary- and tertiary-care facilities in Zhejiang province, China. PARTICIPANTS: Primary care practitioners (PCPs) and hospital specialists. MAIN OUTCOMES: Perceived patients' expectations. RESULTS: Seven focus groups and 21 individuals were interviewed. Questionnaires were completed by 460 PCPs and 651 specialists (response rate: 78%). About 36.8% of doctors reported generating profit for the facility at which they practiced as a foremost consideration. Participants perceived patients as holding high expectations of clinical performance and use of medical products. Respondents perceived that their patients expected either drug prescriptions (48.2%) or intravenous (IV) therapy (45.2%). Perceived patient expectations of an arrangement of tests and consultation fee refunds if no prescriptions were made were reported by 29.7 and 22.7%, respectively. Doctors reported feeling undervalued and disrespected when patients requested consultation fee refunds. Compared to those who did not report a need for profit-making, doctors who did were significantly more likely to perceive that their patients expected medication-based treatments (AOR = 1.62, P < 0.001), IV therapy (AOR = 1.32, P = 0.037), the arrangement of tests (AOR = 2.06, P < 0.001), and consultation fee refunds when no prescriptions were made (AOR = 1.92, P < 0.001). CONCLUSIONS: Most doctors believed that patients had high expectations. Workplace profit-orientation demonstrated a strong association with doctors' perceptions.

ASCO Value Framework Highlights the Relative Value of Treatment Options in Ovarian Cancer.

PURPOSE: The ASCO value framework allows physicians and patients to compare the relative value of novel treatments. Our aim was to assess the value of three frontline ovarian cancer therapies by using this framework. METHODS: From phase III, randomized controlled clinical trial (RCT) data, the net health benefits (NHBs) for three frontline ovarian cancer treatment options-dose-dense paclitaxel (Japanese Gynecologic Oncology Group study JGOG 3016), intraperitoneal (IP)/intravenous (IV) chemotherapy (Gynecologic Oncology Group [GOG] study GOG 172), and concurrent plus maintenance bevacizumab (GOG 218 and the Seventh International Collaborative Ovarian Neoplasm study [ICON7])-were calculated. The ASCO value framework calculates the NHB by using six criteria: clinical benefit, toxicity, tail of the curve, symptom palliation, treatment-free interval, and quality of life. Clinical benefit calculation uses ASCO-assigned importance weights for overall survival and progression-free survival. The maximum possible NHB points is 180. NHBs were presented alongside the drug-acquisition cost (DAC) of each therapy. A benefit-cost ratio of NHB points per additional cost was calculated. RESULTS: The NHB of dose-dense paclitaxel was 38, at an additional cost of $16 per cycle. IP cisplatin/IV + IP paclitaxel received 29 NHB points, at an additional cost of $1,629 per cycle. Concurrent plus maintenance bevacizumab received 24 NHB points, at an additional cost of $7,581 per cycle (GOG 218) or six NHB points ($3,790 per cycle; ICON7). The ratios of NHB points-to-dollar were as follows: dose-dense paclitaxel, 2.4 (highest); IP chemotherapy, 0.018; and bevacizumab, 0.003 (lowest). CONCLUSION: Using the ASCO value framework, we constructed value snapshots of three major frontline therapeutic options in ovarian cancer. Dose-dense paclitaxel provided the highest additional value when analysis accounted for NHB and cost. However, additional research is needed to include individual patient preferences and provide personalized value assessments.