Diagnosis and Treatment Patterns in Celiac Disease.

Celiac disease (CD) is an immune-mediated gastrointestinal (GI) disorder driven by innate and adaptive immune responses to gluten. Presentation of CD has changed over time, with non-GI symptoms, such as anemia and osteoporosis, presenting more commonly. With improved screening and diagnostic methods, the reported prevalence of CD has increased globally, and there is considerable global variation in diagnostic and treatment practices. The objective of this study was to describe the current state of CD diagnosis and treatment patterns. A targeted review of literature from MEDLINE, Embase, the Cochrane Library, and screening of relevant conference abstracts was performed. The generally recommended diagnostic approach is GI endoscopy with small bowel biopsy; however, in selected patients, biopsy may be avoided and diagnosis based on positive serology and clinical symptoms. Diagnosis often is delayed; the average diagnostic delay after symptom onset is highly variable and can last up to 12 years. Barriers to accurate and timely diagnosis include atypical presentation, lack of physician awareness about current diagnostic criteria, misdiagnosis, and limited access to specialists. Currently, strict adherence to a gluten-free diet (GFD) is the only recommended treatment, which is not successful in all patients. Only one-third of patients are monitored regularly following diagnosis. Unmet needs for CD include improvements in the accuracy and timeliness of diagnosis, and the development of treatments for both refractory CD and GFD nonresponsive CD. Further research should investigate the impact of education about gluten-free eating and the availability of gluten-free foods support adherence and improve outcomes in patients with CD.

Systematic Literature Review of the Economic Burden of Celiac Disease.

BACKGROUND: The prevalence of celiac disease (CD) has rapidly increased over recent decades, but costs related to CD remain poorly quantified. OBJECTIVE: This systematic review assessed the economic burden of CD in North America and Europe. METHODS: MEDLINE, EMBASE, EconLit, and the Cochrane Library databases were systematically searched to identify English-language literature from 2007 to 2018 that assessed costs, cost effectiveness, and health resource utilization for CD. RESULTS: Forty-nine studies met the inclusion criteria, of which 28 (57.1%) addressed costs of testing and diagnosis; 33 (67.3%) were from Europe. The cost per positive CD diagnosis of testing patients already undergoing esophagogastroduodenoscopy for other indications ranged from 1300 Canadian dollars ($Can) in Canada (2016 value) to €44,712 in the Netherlands (2013 value). Adding the CD test was cost effective when it combined diagnostic modalities (e.g., serology and biopsy). Direct annual excess costs to a US payer per diagnosed CD patient totaled $US6000 (2013 value) more than for a person without CD, chiefly due to outpatient care. Hospitalizations, emergency visits, and medication use were more common with CD. After initiating a gluten-free diet (GFD), patients visited primary care providers less often, used more medications, and missed fewer days from school and work. CONCLUSIONS: Most of the few available economic studies of CD assess testing and diagnosis costs, especially in Europe. Methods of testing generally are considered cost effective when they combine diagnostic modalities in symptomatic patients. Most costs to a payer of managing CD derive from outpatient care. Following GFD initiation, patients lose fewer days from work and school than pretreatment.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review.

To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.

Gastrointestinal adverse events with combination of checkpoint inhibitors in advanced melanoma: a systematic review.

INTRODUCTION: Immunotherapies, including checkpoint inhibitors (CIs) such as cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed death-1 (PD-1) inhibitors, are revolutionizing the treatment of advanced melanoma. Combining CTLA-4 and PD-1 inhibitors provides additional clinical benefit compared with single agents alone. However, combination therapy can increase the incidence of gastrointestinal adverse events (GI AEs). This systematic review assessed the epidemiological, clinical, economic, and humanistic burden of GI AEs due to combination CIs in advanced melanoma. METHODS: MEDLINE, EMBASE, and the Cochrane Library were systematically searched (December 2011 to December 2016) to identify primary studies, systematic reviews, meta-analyses, and conference proceedings (2014-2016) evaluating adults treated with ≥2 CIs for advanced melanoma. RESULTS: Of the 3391 identified articles, 14 were included. Most studies examined the ipilimumab plus nivolumab combination. Any grade and grade 3-4 GI AEs occurred in more patients receiving ipilimumab plus nivolumab versus ipilimumab or nivolumab alone. The most common grade 3-4 GI AEs were diarrhea and colitis. Grade 3-4 colitis occurred in more patients receiving ipilimumab plus nivolumab. However, grade 3-4 diarrhea occurred at the same rate as ipilimumab alone. GI AEs developed with ipilimumab plus nivolumab approximately 6.6 weeks after initiating treatment. No studies assessing the economic or humanistic burden of GI AEs were identified. CONCLUSION: GI AEs occurred at a higher rate and greater severity in patients treated with ipilimumab plus nivolumab versus ipilimumab or nivolumab monotherapy. The lack of research on economic and humanistic burden of GI AEs with combination CIs for advanced melanoma represents an unmet need in the literature and should be explored in future studies.

Epidemiology and treatment patterns of epithelial ovarian cancer.

INTRODUCTION: While ovarian cancer (OC) is relatively rare, it remains one of the most fatal cancers. Lack of robust screening methods for eOC lead to detection of most cases at advanced stages, and most patients relapse following initial treatment. Areas covered: This review summarizes epidemiology and treatment patterns of epithelial ovarian cancer (eOC). MEDLINE, EMBASE, conference proceedings, and the Cochrane Library were searched using key terms and Medical Subject Headings for ovarian cancer, treatment patterns, and epidemiology to identify articles published from 2005-2015. Expert commentary: To improve early detection, future studies should focus on the identification of biomarkers that can detect asymptomatic disease. Following diagnosis and eventual relapse, response to first-line platinum appears to guide physicians' choice of subsequent therapies, but we do not understand what patients ultimately receive or its relationship to categories of response to first-line platinum. Improved understanding of later-line treatment patterns, by initial response to platinum, could correlate with overall outcomes among relapsed patients and promote development of more effective treatment guidelines. Novel treatment approaches, such as immunotherapies, would fulfill a need for an effective strategy against advanced stages of OC that results in fewer toxic side effects.