Clinical Impact of ASCO Choosing Wisely Guidelines on Staging Imaging for Early-Stage Breast Cancers: A Time Series Analysis Using SEER-Medicare Data.

PURPOSE: American Society for Clinical Oncology released the Choosing Wisely list in 2012, highlighting low-value procedures that lack evidence, advising against the use of positron emission tomography, computerized tomography, and radionuclide bone scans for the staging of early-stage breast cancer at low risk for metastasis. The objective of the study was to assess the impact of the American Society of Clinical Oncology Choosing Wisely guidelines on inappropriate staging imaging among early-stage breast cancers. METHODS: The Surveillance, Epidemiology, and End Results Program-Medicare data set was used to identify 50,004 women age 66 years and older with new incident diagnosis of early-stage breast cancer (stage 0 through stage 2a; T < 4, N = 0, and M = 0). The primary outcome was the incidence of patients with inappropriate imaging following an early-stage breast cancer diagnosis. The primary outcome was identified within 6 months of the first diagnosis. An interrupted time series analysis using negative binomial regression was performed for outpatient claims for these diagnostic studies versus the two interruptions of guidelines release and guidelines reinforcement. Mean images per patient, percent change for the study period, and rate of change per year were calculated. RESULTS: Imaging rates fell by a modest 2.32% following guidelines release in April 2012 (point estimate = -2.32%; 95% CI, -6.34% to 1.88%). By contrast, imaging rates fell by a four-fold larger amount (point estimate = -9.36%; 95% CI, -13.20% to -5.35%) following guidelines published reminders in journals (or reinforcement) in October 2013. Mean imaging studies per patient (95% CI) declined from 1.80 (1.76 to 1.84) in January 2012 to 1.50 (1.48 to 1.53) by January 2015, representing a 16% decline in imaging overuse in 2015 compared with 3 years earlier. The rate of change (95% CI) in images per patient was initially small at -0.47% (-4.27% to 3.33%) per year between April 2012 and October 2013, but almost eight times faster at -3.70% (-5.81% to -1.60%) per year after October 2013. CONCLUSION: This analysis demonstrates a substantial decrease in the prevalence of imaging overuse in early-stage breast cancers correlating with the 2013 reinforcement of American Society of Clinical Oncology's 2012 Choosing Wisely guidelines. The creation and dissemination of such resources serves as a powerful tool to improve clinical practice, cost-effectiveness, and patient safety from secondary malignancies, anxiety, and overdiagnosis.

Exploring the Use of State Medical Cannabis Legislation as a Proxy for Medical Cannabis Use Among Patients Receiving Chemotherapy.

OPINION STATEMENT: The use of medical cannabis is expanding in the USA. Due to conflicting, low-quality evidence, many oncologists may not feel confident to recommend it to patients. Given the potential for legal and financial risks when conducting clinical trials with medical cannabis, the use of observational data should be explored. Observational data that directly capture medical cannabis use in relation to prescription medications and track the prevalence and patterns of cannabis use is sparse. To gain insights into the role medical cannabis plays in the pharmaceutical landscape, proxies such as cannabis legislation need to be explored. In the context of recommendation-nonadherent antiemetic prescribing among patients experiencing chemotherapy-induced nausea and vomiting, medical cannabis may be a suitable alternative to an antiemetic in states that allow medical cannabis. Findings suggest that legislation may impact the use of certain antiemetics in states with cannabis legislation in place. The presence or absence of legislation regarding medical cannabis use may serve as an early, observable surrogate marker of medical cannabis use in the community. In light of the paucity of clinical trials and observational datasets that capture cannabis use, there remains a tremendous need for the development of methodologies or standardized datasets that appropriately and reliably capture the use of medical cannabis to facilitate research into its clinical application and effect on prescription medication use. Standardizing the reporting and destigmatizing use could eliminate the dependence upon proxy measures as a substitute for more extensive data and go a long way in improving data capture, thus allowing us to generate knowledge and hypotheses from observational data until research conditions improve and allow for expanded clinical trials involving medical cannabis.

Nonprescription Medication Use in Hospice Patients.

OBJECTIVE: Patients admitted to hospice are more vulnerable to age-related physiologic changes, polypharmacy, and inappropriate medication use and monitoring. The objective of this study was to characterize the utilization of nonprescription medications in a hospice population. METHODS: This was a retrospective study designed to characterize nonprescription or over-the-counter medication use in hospice patients. Data for this study were provided by Seasons Hospice & Palliative Care, a national hospice organization with licenses to operate in 19 states and collected from January 1 to December 31, 2016. The most frequently utilized nonprescription medications, therapeutic classes, and the frequency of patients with at least 1 claim within a therapeutic class were summarized. RESULTS: The final study population included 62 639 orders representing 15 164 patients. The average age was 79.31 years with a standard deviation of 13.31 years. The average length of stay was 26.80 days with a standard deviation of 44.14 days. The top 5 most common medications were as follows: acetaminophen (25.15%), bisacodyl (21.69%), senna (8.35%), omeprazole (4.51%), and docusate (4.46%). Approximately 13 714 (29.67%) of patients were exposed to analgesics, 13 469 (29.14%) to laxatives, and 3535 (7.65%) to antacids or antigas medications. CONCLUSION: This study highlights numerous opportunities for improvement in the use of nonprescription medications among hospice patients. Reducing the use of nonprescription medications that are ineffective or produce unwanted side effects can contribute to improving the quality of care that patients receive.