Comparative Life-Cycle assessment of microalgal biomass production in conventional growth media versus newly developed nanoemulsion media.

Microalgae biomass is a potential feedstock for biodiesel, animal feed, biofertilizer, and other products such as bioactive compounds. Most of the reported studies describe microalgae as a green process, however, the impacts associated with its growth media and cultivation have seldom been studied. With an aim to analyze the environmental impacts, the present study compares the life-cycle assessment of microalgal cultivation in two growth media. The data used was obtained from the experimental sets where microalgaeC. pyrenoidosawas cultivated in BG11 (control or SC-1) and silicone oil nanoemulsion (previously developed medium or SC-2) on a lab scale. The environmental impacts were evaluated using the ReCiPe midpoint and endpoint method using Sima Pro 9.0 software based on a "cradle-to-gate" approach. The total environmental score for 1 kg microalgal biomass production was 99.25Pt in SC-1, and 53.39Ptin SC-2, concluding greater environmental burden by SC-1. The photobioreactor construction material along with the operation led to maximum emissions, human toxicity, and resource depletion. In summary, the newly developed nanoemulsion medium was found to be eco-friendly that has the potential to minimize the usage of conventional nutrients and resources.

Cattle wastewater as a low-cost supplement augmenting microalgal biomass under batch and fed-batch conditions.

The utilization of costly chemical fertilizers and large freshwater requirements make the microalgae cultivation process uneconomical and highly unsustainable. To address this challenge, the present study aimed to integrate cattle wastewater (CW) (alternate for fertilizers) with domestic sewage wastewater (DSW) (substitute for freshwater) to cultivate Chlorella thermophile. To maximize the biomass yield, in-depth nutrient consumption patterns in both batch and fed-batch cultivation conditions were analyzed. Out of the eight (1%-4.5%) different CW feed concentrations tested during the batch cultivation, 2.5% CW set gave the highest biomass yield (2.17 g L-1), which was almost double the yield obtained using Bold Basal Medium (1.24 g L-1) and DSW without any CW addition (1.22 g L-1). However, the biomass yield declined with CW> 2.5%, and the ammonium (NH4+) inhibitory effect was observed. To address the (NH4+) toxicity challenge and further enhance the biomass yield, fed-batch experiments were designed with an intermittent CW feeding based on nutrient (NH4+) consumption pattern. The fed-batch cultivation resulted in twofold increased biomass yield (4.52 g L-1) in comparison to the batch process. The nutrient consumption pattern inferred that the (NH4+) concentration greater than 600 mg L-1 during the logarithmic phase was inhibitory for Chlorella thermophila cells. On biomass characterization, a significant improvement in protein content with CW addition was observed. The FAME analysis of the derived lipid stated its competitive biofuel quality with up-gradation of C:16 and C:18 groups. Based on the obtained results, projection analysis for an integrated rural model demonstrated the technology's potential for sustainable water management with valuable resource recovery.

Children's Color Trail Test for Objective Assessment of Attention in Children with Attention Deficit Hyperactivity Disorder: A Diagnostic Accuracy Study.

OBJECTIVE: To compare the Children's Color Trail Test scores in children with and without Attention Deficit Hyperactivity Disorder to assess its diagnostic performance in assessing attention-deficit. METHODS: 50 children with Attention Deficit Hyperactivity Disorder (diagnosed as per Diagnostic and Statistical Manual, 5th edition) and 50 age- and sex-matched children underwent Test 1 and Test 2 of the Children's Color Trail Test. A Receiver Operating Characteristics curve was constructed for the diagnostic accuracy of Children's Color Trail Test in Attention Deficit Hyperactivity Disorder. RESULTS: The Receiver Operating Characteristics curve showed a score ≤32 for Children's Color Trail Test 1 [AUC: 0.8 (0.71 to 0.87); P<0.001] and score ≤40 for Children's Color Trail Test 2 [AUC: 0.85 (0.77 to 0.92); P<0.001] as the best cut-off for diagnosing Attention Deficit Hyperactivity Disorder. CONCLUSIONS: Children's Color Trail Test is a promising tool for diagnosing attention deficit, and could be used in settings where parent or teacher reports are not available.

Travel burden associated with rare cancers: The example of Merkel cell carcinoma.

BACKGROUND: There are limited data on the travel burden for cancer patients with rare tumor types, such as Merkel cell carcinoma (MCC). OBJECTIVE: The objective of this study was to understand the travel burden of MCC patients. METHODS: This study used data from an MCC registry at the Seattle Cancer Care Alliance (SCCA). All MCC patients enrolled at SCCA with a valid 3-digit ZIP code were included. Patients were followed up from January 1, 2012 until their last follow-up, death, or end of data (January 1, 2017). Travel burden was measured by one-way travel distance to SCCA from each patient's 3-digit ZIP code. Patient demographics, tumor characteristics, and follow-up visit were evaluated and stratified by one-way driving distance of ≤300 and >300 miles. RESULTS: A total of 391 MCC patients were included (68% men, mean age = 67 years [±SD = ±11 years], 67% residing in the West, and 70% white). At diagnosis, 53% of the patients had Stage III or IV MCC. Mean one-way distance traveled by patients was 1,137 (median: 813) miles, and 57% of patients traveled >300 miles. Compared to patients who traveled ≤300 miles, those who traveled >300 miles were more likely to be <70 years old (46% vs 65%; P < 0.001), were diagnosed with advanced stage (III or IV) MCC (46% vs 59%; P = 0.01), had shorter follow-up in the cancer registry (mean: 509 vs 212 days; P < 0.001), and had fewer visits during follow-up (mean: 5.2 vs 2.5; P < 0.001). CONCLUSIONS: In this single cancer center study, the majority of MCC patients trav-eled long distances to receive expert care. Longer travel distances appeared to be associated with younger age, a more advanced stage of cancer at study entry and fewer in-clinic visits, suggesting that travel burden may impact timely and adequate patient care for this rare cancer.

Treatment and persistence with oral anticoagulants among newly diagnosed patients with non-valvular atrial fibrillation: a retrospective observational study in a US commercially insured and Medicare Advantage population.

OBJECTIVES: With the approval of new non-vitamin K antagonist oral anticoagulants for stroke prevention in non-valvular atrial fibrillation (NVAF), it is anticipated that their introduction may change NVAF treatment patterns; however, there is limited supporting real-world evidence. This study investigated guideline-recommended oral anticoagulation (OAC) treatment and persistence in newly diagnosed patients with NVAF to understand demographic and clinical characteristics. DESIGN: Retrospective observational administrative claims study in the USA. SETTING: Patients with NVAF with ≥1 pharmacy claim for OAC (warfarin, dabigatran, rivaroxaban or apixaban) and no atrial fibrillation diagnosis within 12 months prior to the first claim were identified in the HealthCore Integrated Research Database between 1 November 2010 and 30 November 2013. PARTICIPANTS: 45 092 patients with NVAF were included. OUTCOMES: The proportion of OAC-treated patients was stratified by CHADS2 score. Treatment persistence was measured from OAC initiation to discontinuation, end of eligibility or end of study period (30 November 2014), whichever occurred first. RESULTS: Almost half of the patients (41.1%) received an OAC. The proportion treated differed slightly in baseline stroke risk (CHADS2<2: 39.8%; CHADS2=2 or 3: 42.4%; and CHADS2>3: 40.3%: p<0.001). Treated patients were slightly younger (70±12.2 vs 71±14.3 years; p<0.001), more likely male (59.7% vs 52.5%; p<0.001) and had a slightly elevated stroke risk (CHADS2: 2.03±1.3 vs 1.98±1.4; p<0.001) and a lower bleeding risk (HEMORR2HAGES: 2.55±1.8 vs 2.80±1.9; p<0.001) relative to untreated patients. Overall, patients with higher CHADS2 scores had higher HEMORR2HAGES scores. The mean follow-up was 2.25 years (2.25±0.85) and 72.7% of patients discontinued OACs; nearly 25% within 3 months and 55% within 12 months. The mean time to discontinuation was 255±249 days. CONCLUSIONS: The proportion of patients with NVAF who received OAC treatment was lower than previously reported and differed slightly by stroke risk. Patients with an elevated stroke risk had a higher bleeding risk, suggesting that clinicians may incorporate both in the treatment decision.

Health Care Resource Utilization and Costs Among Newly Diagnosed and Oral Anticoagulant-Naive Nonvalvular Atrial Fibrillation Patients Treated with Dabigatran or Warfarin in the United States.

BACKGROUND: Warfarin has a long history of use to reduce the risk of stroke in patients with atrial fibrillation (AF), but it requires frequent laboratory monitoring to maintain international normalized ratio levels in the therapeutic range. Dabigatran, a novel oral anticoagulant (OAC), has demonstrated efficacy in reducing the risk of stroke and systemic embolism and does not require laboratory monitoring. OBJECTIVE: To compare health care resource utilization (HCRU) and costs of OAC-naive patients newly diagnosed with nonvalvular atrial fibrillation (NVAF), using dabigatran or warfarin. METHODS: This retrospective observational study used data from medical and pharmacy claims extracted from the HealthCore Integrated Research Database representing commercial and Medicare Advantage members. Adults aged > 18 years with a medical diagnosis claim of NVAF were identified between October 1, 2010, and December 31, 2011. The date of first observed OAC prescription claim was the index date. Patients were followed for up to 12 months after the index date. Patients were assigned to the dabigatran or warfarin treatment groups based on their first OAC prescription fills. To reduce potential for selection bias, the cohorts were matched on baseline characteristics using propensity score matching. HCRU was measured and compared between groups on a per-patient-per-month (PPPM) basis for all-cause HCRU, as well as stroke, myocardial infarction, and bleed-specific HCRU. Pharmacy, medical, and total costs were also compared and adjusted to 2012 U.S. dollars. Generalized linear models were conducted to compare all-cause health care costs between cohorts. RESULTS: After propensity score matching, 1,648 patients were included in the analysis (824 each in the dabigatran and warfarin treatment groups). In the post-index period, patients in the dabigatran group had significantly fewer all-cause PPPM physician office visits (mean [SD] 1.29 [± 0.95] vs. 2.02 [± 1.53], P < 0.001) and outpatient visits (mean [SD] 2.17 [± 2.90] vs. 3.52 [± 3.32], P < 0.001) compared with those in the warfarin group. There were no between-group differences in outcomes for the number of stroke, myocardial infarction, or bleeding-related office visits. All-cause medical costs for the dabigatran cohort were lower than the warfarin cohort; however, the difference did not reach statistical significance ($2,696 [SD ± $6,699] vs. $2,893 [± $6,819], P = 0.179). All-cause pharmacy costs were higher in the dabigatran group versus the warfarin group ($455 [± $429] vs. $328 [± $517], P < 0.001). The dabigatran cohort also had significantly higher stroke-related ($32 [± $71] vs. $20 [± $55], P = 0.006) and nonstroke-related pharmacy costs ($423 [± $422] vs. $308 [± $515], P < 0.001). Despite higher pharmacy costs for the dabigatran cohort, both treatment groups had statistically similar all-cause total costs ($3,151 [± $6,744] vs. $3,221 [± $6,869], P = 0.701). CONCLUSIONS: This real-world study showed that among patients newly diagnosed with NVAF who were OAC naive, dabigatran use was associated with significantly less HCRU in terms of physician and outpatient visits but higher pharmaceutical costs in up to 12 months of follow-up. Similar to other real-world studies, this research supports the finding that higher pharmacy costs for dabigatran users was offset by lower medical costs, making total health care costs comparable between dabigatran and warfarin. DISCLOSURES: This work was supported by Boehringer Ingelheim Pharmaceuticals, which is the manufacturer of dabigatran, one of the products included in the analysis of this work. The authors were responsible for all content and editorial decisions. Jain and Tan are employed by HealthCore, a research consultancy which was funded by Boehringer Ingelheim Pharmaceuticals for work on this study. Fu was employed by HealthCore at the time of this study. Lim, Wang, Elder, and Sander are employees of Boehringer Ingelheim Pharmaceuticals. Study concept and design were contributed by Wang, Sander, and Tan, along with Fu and Jain. Fu, Tan, and Jain collected the data, and data interpretation was performed by Lim, Wang, and Sander, along with Jain, Tan, and Fu. The manuscript was written by Jain, Elder, Tan, and Wang, along with Lim and Fu, and revised by Jain, Wang, Elder, and Tan. Some of the results of this study were presented at Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke (QCOR) 2014 Scientific Sessions on June 2-4, 2014, in Baltimore, Maryland.

Effect of comorbidities and medications on frequency of primary care visits among older patients.

OBJECTIVE: To determine if comorbidities and high-risk medications affect the frequency of family physician visits among older patients. DESIGN: Retrospective chart review. SETTING: Academic family health team at Sunnybrook Health Sciences Centre in Toronto, Ont. PARTICIPANTS: Among patients aged 65 years and older who were registered patients of the family health team between July 1, 2013, and June 30, 2014, the 5% who visited their family physicians most frequently and the 5% who visited their family physicians least frequently were selected for the study (N = 265). MAIN OUTCOME MEASURES: Predictors of frequent visits to family physicians. RESULTS: The significant predictors of being a high-frequency user were female sex (odds ratio [OR] = 2.20, P = .03), age older than 85 years (OR = 5.35, P = .001), and higher total number of medications (OR = 1.49, P < .001). Age-adjusted Charlson comorbidity index score, number of Beers criteria medications, and Anticholinergic Risk Scale score were not significant predictors (P > .05). CONCLUSION: Female sex, age older than 85, and higher total number of medications were independent significant predictors of higher frequency of family physician visits among older patients. Validated tools, such as the Charlson comorbidity index, Beers criteria, and Anticholinergic Risk Scale, did not independently predict the frequency of visits, indicating that predicting frequency of visits is likely complex.

Health Information Exchange Readiness for Demonstrating Return on Investment and Quality of Care.

OBJECTIVE: To study the extent to which community health information exchanges (HIEs) deliver and measure return on investment (ROI) and improvements in the quality of care. MATERIALS AND METHODS: We surveyed operational HIEs for their characteristics, information domains, impact on quality of care, and ROI. RESULTS: A 60 percent response rate was achieved. Two-thirds of respondents agreed that community HIEs demonstrated a positive ROI, while one-third had no opinion or disagreed. One-fourth or fewer respondents reported using various metrics to calculate ROI. Most respondents agreed that HIEs improve the quality of care, though several were not sure and were awaiting further evidence. Most respondents indicated that they did not deliver reports on quality measures (76 percent) and that data were not being used to measure quality performance of participating providers (73 percent). DISCUSSION: Respondents from most HIEs believe that the HIEs are demonstrating a positive ROI; however, a minority of them indicated they had used or will use specific metrics to calculate ROI. HIE representatives overwhelmingly reported that they believe the HIE activities improve the quality of healthcare delivered, but only a few are using data to evaluate provider performance or generate reports on quality measures. CONCLUSION: This study demonstrates the challenge faced by policy makers and healthcare organizations that are investing millions of dollars in HIEs that are believed to improve health outcomes and increase efficiency, but still need more time to develop the evidence to confirm that belief. Our study shows that calculating ROI for HIEs or their impact on quality of care remains a secondary priority for most HIEs. This finding raises serious questions for the sustained support of HIEs, both financially and as a policy lever, given the end of Health Information Technology for Economic and Clinical Health (HITECH) Act funding.

Roflumilast: Who Is Using It and How It Affects Health Care Resource Utilization and Costs.

OBJECTIVE: Compare baseline characteristics, health care resource utilization (HCRU), and associated costs of COPD patients treated with add-on roflumilast with those of other combination medications. DESIGN: Retrospective cohort study. METHODOLOGY: Patients aged 40 years with a diagnosis of chronic obstructive pulmonary disease (COPD) between March 1, 2011, and Nov. 30, 2012, were identified from the HealthCore Integrated Research Database and classified as roflumilast or nonroflumilast combination-therapy cohorts. Baseline characteristics were compared for all patients. HCRU and costs were compared between matched (M) roflumilast and nonroflumilast cohorts, using propensity score as a partial balancing score and then complementing the score with exact matching on specifically important variables. Generalized linear model and Poisson regression were used to estimate the adjusted differences in total costs and hospitalization rates, respectively, between the 2 matched cohorts. RESULTS: A total of 695 roflumilast and 30,542 nonroflumilast combination therapy users were identified. At baseline, the roflumilast cohort had more complex COPD and a higher number of severe and moderate COPD exacerbations relative to the nonroflumilast cohort. After matching, the roflumilast (M) and nonroflumilast (M) cohorts (n = 328 in each) had similar mean age, gender distribution, and follow-up time. The roflumilast (M) cohort had significantly higher pharmacy-related, per-patient, per-month (PPPM) costs (P < .001) and similar total cost (P = .90). After adjusting for confounding variables, no difference was observed between the 2 cohorts in total costs (P = .86) and number of hospitalizations (P = .65). CONCLUSION: Findings suggest that patients in the roflumilast cohort, relative to the nonroflumilast cohort, were more severely ill in the real-world setting. Despite higher pharmacy costs, the total cost for the roflumilast cohort was statistically similar to the nonroflumilast cohort. Future studies with longer follow-up are needed to evaluate the long-term economic impact of roflumilast use.

Cardiovascular-related healthcare resource utilization and costs in patients with hypertension switching from metoprolol to nebivolol.

BACKGROUND: The prevalence of hypertension is increasing in the United States and the associated costs are soaring. Despite the many treatment options, only approximately 50% of Americans with hypertension achieve optimal control. Patients receiving nebivolol, a third-generation beta-blocker, have fewer adverse events and better treatment persistence compared with patients receiving other antihypertensive agents. Little is known about the impact of switching from a second-generation beta-blocker, such as metoprolol, to nebivolol on healthcare resource utilization and costs. OBJECTIVE: To assess the impact of switching patients with hypertension from metoprolol to nebivolol on the associated healthcare resource utilization and cost. METHOD: This retrospective claims-based analysis included 765 adults aged ≥18 years who were diagnosed with hypertension between January 1, 2008, and December 31, 2012. Data were extracted from the HealthCore Integrated Research Database; the study was conducted between July 1, 2007, and June 30, 2013. To be included in the study, patients had to receive metoprolol for ≥6 months before switching from metoprolol to nebivolol (the preperiod), and continue to use nebivolol for an additional 6 months after switching (the postperiod). Patients with compelling indications for metoprolol but not for nebivolol were excluded from the study. The primary outcome measures were healthcare resource utilization and costs for cardiovascular (CV)-related events. The CV-related resource utilization was calculated based on 100 patients per month; the CV-related costs were calculated per patient per month (PPPM) in 2013 US dollars. RESULTS: A total of 765 patients were included in the analysis. Compared with the preperiod, patients switching to nebivolol had significantly fewer CV-related emergency department visits (0.2 [standard deviation (SD), 1.9] vs 0.04 [SD, 0.8], respectively; P = .012) and fewer CV-related outpatient visits (9.2 [SD, 19.9] vs 6.7 [SD, 17.5], respectively; P <.001). The numbers of inpatient visits in the preperiod and postperiod were similar (0.3 [SD, 2.4] vs 0.1 [SD, 1.5], respectively; P = .164). Patients switching to nebivolol also had significantly lower CV-related emergency department costs ($6 [SD, $78] vs $1 [SD, $27] PPPM, respectively; P = .028) and lower CV-related total medical costs ($94 [SD, $526] vs $54 [SD, $266] PPPM, respectively; P = .020). CONCLUSION: This analysis of real-world data suggests that patients with hypertension who switch from the second-generation antihypertensive metoprolol to the third-generation hypertensive nebivolol have significantly lower CV-related healthcare resource utilization (eg, emergency department and outpatient visits) and lower CV-related medical costs.

A primer on marginal effects--Part I: Theory and formulae.

Marginal analysis evaluates changes in an objective function associated with a unit change in a relevant variable. The primary statistic of marginal analysis is the marginal effect (ME). The ME facilitates the examination of outcomes for defined patient profiles while measuring the change in original units (e.g., costs, probabilities). The ME has a long history in economics; however, it is not widely used in health services research despite its flexibility and ability to provide unique insights. This paper, the first in a two-part series, introduces and illustrates the calculation of the ME for a variety of regression models often used in health services research. Part One includes a review of prior studies discussing MEs, followed by derivation of ME formulas for various regression models including linear, logistic, multinomial logit model (MLM), generalized linear model (GLM) for continuous data, GLM for count data, two-part model, sample selection (two-stage) model, and parametric survival model. Prior theoretical papers in health services research reported the derivation and interpretation of ME primarily for the linear and logistic models, with less emphasis on count models, survival models, MLM, two-part models, and sample selection models. These additional models are relevant for health services research studies examining costs and utilization. Part Two of the series will focus on the methods for estimating and interpreting the ME in applied research. The illustration, discussion, and application of ME in this two-part series support the conduct of future studies applying the marginal concept.

Benefits Improvement and Protection Act's impact on transplantation rates among elderly MEDICARE beneficiaries with end-stage renal disease.

BACKGROUND: The Benefits Improvement and Protection Act (BIPA) expanded Medicare coverage for posttransplantation immunosuppresants for elderly patients and others eligible for Medicare beyond their end-stage renal disease (ESRD) status yet retained the 3-year limit for patients eligible solely because of ESRD status. Our objective was to determine BIPA's impact on renal transplantation among elderly patients (age ≥65 years) affected by BIPA. METHODS: Medicare claims and the U.S. Renal Data System Standard Analysis Files were used to analyze the likelihood of transplantation among elderly patients, all of whom were affected by BIPA, versus the nonelderly, many of whom were unaffected by BIPA. A difference-in-differences approach and generalized logistic regressions were used to estimate BIPA's impact. RESULTS: Analysis of data for 632,904 ESRD Medicare beneficiaries who met inclusion/exclusion criteria suggests that BIPA made elderly patients more likely (relative likelihood, 1.36; 95% confidence interval, 1.32-1.41) to have a transplant. The likelihood for nonelderly patients decreased following BIPA (relative likelihood, 0.93; 95% confidence interval, 0.92-0.94). CONCLUSION: Transplantation rates increased among those elderly patients, all of whom were affected by BIPA by extending immunosuppressant coverage under BIPA. These results suggest that removing financial barriers to posttransplantation care may positively impact transplantation rates yet raise questions regarding whether the law shifted transplants from younger to older patients.

Food insecurity is negatively associated with home health and out-of-pocket expenditures in older adults.

Food insecurity is a persistent, growing, and clinically relevant problem in older adults; however, its effect on healthcare expenditures is not known. This study examined the relationship of food insecurity with Medicare and out-of-pocket expenditures in older Georgians enrolled in Medicare and meal services using 2 complementary datasets: Georgia Advanced Performance Outcomes Measures Project 6 (GA Advanced POMP6) and Medicare claims data in 2008 (n = 903, mean age 76.9 ± 7.8 y, 31.0% male, 64.2% white). Due to the mixed distribution of healthcare expenditure data (e.g., high nonusers, right-skewed distribution for users), 2-part models were used. Approximately one-half of the sample was food insecure (50.4%) and was more likely to report poorer health status and to have chronic diseases than food-insecure individuals. Food-insecure older adults were less likely to have any Medicare expenditure than food-secure older adults. Among those who had positive Medicare expenditure, however, food-insecure and food-secure individuals had similar Medicare expenditures. Food-insecure and food-secure older individuals were equally likely to incur out-of-pocket expenditure. However, among those who had positive out-of-pocket expenditure, food-insecure older individuals had lower out-of-pocket expenditures than their counterparts. Adjusted mean Medicare and out-of-pocket expenditures of food-insecure individuals were $1875 and $310 less than food-secure individuals in 2008, respectively. These findings based on the innovative methodological approaches and datasets suggest complex relationships between food insecurity and healthcare expenditures in older adults, reflecting unique healthcare access and usage patterns.

Availing services for developmental disabilities: parental experiences from a referral center in developing country.

OBJECTIVES: To identify the problems faced by parents of children with developmental disabilities in availing rehabilitative services and to find their satisfaction level. METHODS: This study was carried out at a Child Development Clinic (CDC) located in Northern India. Children with developmental disabilities, who were availing services at CDC for at least last 3 mo and had at least 3 follow-up visits, were enrolled. A questionnaire pertaining to the socio-demographic profile, problems faced in availing services and satisfaction level was filled by the parents of the enrolled children. RESULTS: During the study period, 161 parents filled the questionnaire. 77.6% had some problems in getting the services, the major being difficulty in commuting (50%) and financial constraint (21.7%). More than 80% parents use public transport to reach CDC with 19% travelling more than 50 Km. 29.8% had difficulty in bringing their child to the clinic, either due to severe behavioral problems or physical disability. However, majority of the families were well satisfied with the services as 95% of them graded their satisfaction level at 3 or more on the scale of 0-5. CONCLUSIONS: Parents of children with developmental disabilities face many problems in getting rehabilitative services. They travel long distances, face hardships in carrying their child, and lose their day's earnings, apart from spending time and money for their child's therapy. However, most of the parents are well satisfied with the services.

Racial variation in the cost-effectiveness of chemotherapy for prostate cancer.

PURPOSE: Heterogeneity of treatment effects and expenditures impacts the cost-effectiveness of health interventions. This study investigates the variation in costs, effects, and incremental cost-effectiveness ratios (ICERs) associated with chemotherapy in elderly patients with metastatic (M1) prostate cancer (PC) across race/ethnicity subgroups (non-Hispanic whites, non-Hispanic blacks, and others). STUDY DESIGN: Retrospective observational analysis. METHODS: We examined patients age 66 years or older, identified by using the linked Surveillance, Epidemiology, and End Results-Medicare data set, who were diagnosed with M1 PC between 2000 and 2005. Cost data on the basis of Medicare reimbursements were available for 36 months after diagnosis. Mean costs and effects (life-years gained [LYG]) were adjusted for censoring. The baseline scenario examined PC-specific medical costs at 24 months and required survival of at least three months. Sensitivity analysis considered sampling uncertainty, selection into treatment, and adjustments to initial model assumptions. RESULTS: We identified 3,888 patients with M1 PC, of whom 24% (n = 930) received chemotherapy (primarily docetaxel and mitoxantrone). Twenty percent of observations were censored. The full sample ICER was $99,146 per LYG (95% CI, $75,042 to $130,195). Estimates for whites (ICER, $107,095; 95% CI, $78,391 to $148,272), blacks (ICER, $59,887; 95% CI, $22,860 to $121,509), and others (ICER, $123,909; 95% CI, $37,782 to $366,376) suggest considerable variation in the likelihood of chemotherapy being cost-effective. Results were similar in sensitivity analysis. CONCLUSION: Chemotherapy use in elderly patients with M1 PC is associated with an ICER of $99,146 per LYG. Subgroup analysis revealed heterogeneity in point estimates and considerable statistical uncertainty. To generate a reliable evidence base, efforts to increase the representation of minorities in health care data sets need to continue.

Racial variation in the cost-effectiveness of chemotherapy for prostate cancer.

OBJECTIVE: Heterogeneity of treatment effects and expenditures impacts the cost-effectiveness of health interventions. This study investigates the variation in costs, effects, and incremental cost-effectiveness ratios (ICERs) associated with chemotherapy in elderly patients with metastatic (M1) prostate cancer (PC) across race/ethnicity subgroups (non-Hispanic whites, non-Hispanic blacks, and others). STUDY DESIGN: Retrospective observational analysis. METHODS: We examined patients 66 years or older, identified by using the linked Surveillance, Epidemiology, and End Results-Medicare data set, who were diagnosed with M1 PC between 2000 and 2005. Cost data on the basis of Medicare reimbursements were available for 36 months after diagnosis. Mean costs and effects (life-years gained [LYG]) were adjusted for censoring. The baseline scenario examined PC-specific medical costs at 24 months and required survival of at least 3 months. Sensitivity analysis considered sampling uncertainty, selection into treatment, and adjustments to initial model assumptions. RESULTS: We identified 3888 patients with M1 PC, of whom 24% (n = 930) received chemotherapy (primarily docetaxel and mitoxantrone). Twenty percent of observations were censored. The full sample ICER was $99,146 per LYG (95% confidence interval [CI], $75,042 to $130,195). Estimates for whites (ICER, $107,095; 95% CI, $78,391 to $148,272), blacks (ICER, $59,887; 95% CI, $22,860 to $121,509), and others (ICER, $123,909; 95% CI, $37,782 to $366,376) suggest considerable variation in the likelihood of chemotherapy being cost-effective. Results were similar in sensitivity analysis. CONCLUSION: Chemotherapy use in elderly patients with M1 PC is associated with an ICER of $99,146 per LYG. Subgroup analysis revealed heterogeneity in point estimates and considerable statistical uncertainty. To generate a reliable evidence base, efforts to increase the representation of minorities in healthcare data sets need to continue.

Sensitivity analysis in cost-effectiveness studies: from guidelines to practice.

Cost-effectiveness analysis (CEA) is one of the main tools of economic evaluation. Every CEA is based on a number of assumptions, some of which may not be accurate, introducing uncertainty. Sensitivity analysis (SA) formalizes ways to measure and evaluate this uncertainty. Specific sources of uncertainty in CEA have been noted by various researchers. In this work, we consolidate across all sources of uncertainty, discuss the imbalanced attention to SA across different sources, and discuss criteria for conducting and reporting SA to help bridge the gap between guidelines and practice. Guidelines on how to perform SA have been published for many years in response to requests for greater standardization among researchers. Decision makers tasked with reviewing new health technologies also seem to appreciate the additional information conveyed by a robust SA, including the attention to important patient subgroups. Yet, past reviews have shown that there is a substantial gap between the guidelines' suggestions and the quality of SA in the field. Past reviews have also focused on one or two but not all three sources of uncertainty. The objective of our work is to comprehensively review all different sources of uncertainty and provide a concise set of criteria for conducting and presenting SA, stratified by common modelling approaches, including decision analysis and regression models. We first provide an overview of the three sources of uncertainty in a CEA (parameter, structural and methodological), including patient heterogeneity. We then present results from a literature review of the conduct and reporting of SA based on 406 CEA articles published between 2000 and mid-2009. We find that a minority of papers addressed at least two of the three sources of uncertainty, with no change over time. On the other hand, the use of some sophisticated techniques, such as probabilistic SA, has surged over the past 10 years. Lastly, we identify criteria for reporting uncertainty-robust SA and also discuss how to conduct SA and how to improve the reporting of SA for decision makers. We recommend that researchers take a more comprehensive view of uncertainty when planning SA for an economic evaluation.

Reader- and instrument-dependent variability in the electrocardiographic assessment of arrhythmogenic right ventricular dysplasia/cardiomyopathy.

INTRODUCTION: Despite the use of standardized definitions, widely varying prevalence estimates of electrocardiographic (ECG) features related to arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) have been reported in different cohorts. This study was aimed at examining the variability in the ECG interpretation resulting from the same reader, different readers, and using different ECG-resolutions. METHODS AND RESULTS: Blinded to other clinical data, 2 readers examined quantitative and qualitative ECG features of 20 (10 ARVD/C) randomly selected individuals. ECGs were recorded at standard-speed (SS) and double-speed-double-amplitude (DS) settings. The SS ECGs were scanned, magnified 4×, and evaluated using electronic calipers (EL). One reader repeated all measurements. For both readers, the intraclass correlation coefficient (ICC) for the measurement of QRS duration was good between conventional and electronic evaluation [DS vs EL: Reader 1--0.64 (0.52-0.73); Reader 2--0.67 (0.55-0.76)][SS vs EL: Reader 1--0.60 (0.47-0.70); Reader 2--0.60 (0.47-0.70)]. Using the same resolution, the intrareader ICC was good for SS [0.70 (0.59-0.78)], DS [0.85 (0.80-0.90)], and EL [0.70 (0.69-0.83)] resolutions, but deteriorated for interreader comparisons [0.50 (0.36-0.62), 0.75 (0.66-0.82), and 0.75 (0.66-0.82), respectively]. For qualitative parameters, the intra- and interreader agreement was inconsistent for all but 2 parameters. Both readers were in perfect agreement while interpreting right precordial T-wave inversion [κ= 1] and right bundle branch block morphology (RBBB) [κ= 0.83 (0.5-1.0)] even when using SS resolution. CONCLUSIONS: Right precordial t-wave inversion and RBBB are the only ECG parameters that can be detected consistently even using the conventionally used ECG-resolution. The substantial variability in evaluation of other parameters is not improved even with the use of higher resolutions.

A survey of nephrologists' views on preemptive transplantation.

BACKGROUND AND OBJECTIVES: Despite emerging evidence that preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease (ESRD), it is underutilized. Nephrologists' views on preemptive transplantation are explored herein. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A web-based survey elicited barriers to preemptive transplantation as perceived by nephrologists as well as demographic and practice variables associated with a favorable attitude toward preemptive transplantation. RESULTS: Four hundred seventy-six of 5,901 eligible nephrologists responded (8% participation rate). Seventy-one percent of respondents agreed that preemptive transplantation is the best treatment modality for eligible chronic kidney disease (CKD) patients reaching ESRD, 69% reported that late referrals did not allow enough time for patients to be evaluated for preemptive transplantation, and 50% stated that there was too much delay between a patient's referral and the time the patient was seen at the transplant center. Nephrologists agreed to a lesser extent that they should be held accountable for CKD patients' education (26%) and preemptive transplant referrals (23%). The most important patient factors considered when deciding not to discuss preemptive transplant were poor health status (70%), lack of compliance (69%), other medical problems (51%), being too old (40%), lack of prescription coverage (37%), and lack of health insurance to cover the costs of the procedure (36%). CONCLUSIONS: Surveyed nephrologists consider preemptive transplantation as the optimal treatment modality for eligible patients. Late referral, patient health and insurance status, and delayed transplant center evaluation are perceived as major barriers to preemptive transplantation.

Principles of economics crucial to pharmacy students' understanding of the prescription drug market.

Many pharmacy schools have increased the amount of economics coursework to which pharmacy students are exposed in their prepharmacy and pharmacy curriculums. Students obtain competencies aimed at understanding the basic concepts of microeconomic theory, such as supply and demand. However, pharmacy students often have trouble applying these principles to real world pharmaceuticals or healthcare markets. Our objective is to make economics more relevant for pharmacy students. Specifically, we detail and provide pharmacy-relevant examples of the effects of monopoly power, barriers to marketplace entry, regulatory environment, third party insurance, information asymmetry and unanticipated changes in the marketplace on the supply and demand for pharmaceuticals and healthcare services.