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1.
Artigo em Inglês | MEDLINE | ID: mdl-32542493

RESUMO

African American (AA) populations experience persistent health disparities in the USA. Low representation in bio-specimen research precludes stratified analyses and creates challenges in studying health outcomes among AA populations. Previous studies examining determinants of bio-specimen research participation among minority participants have focused on individual-level barriers and facilitators. Neighborhood-level contextual factors may also inform bio-specimen research participation, possibly through social norms and the influence of social views and behaviors on neighbor's perspectives. We conducted an epidemiological study of residents in 5108 Chicago addresses to examine determinants of bio-specimen research participation among predominantly AA participants solicited for participation in the first 6 years of ChicagO Multiethnic Prevention and Surveillance Study (COMPASS). We used a door-to-door recruitment strategy by interviewers of predominantly minority race and ethnicity. Participants were compensated with a $50 gift card. We achieved response rates of 30.4% for non-AA addresses and 58.0% for AA addresses, with as high as 80.3% response among AA addresses in low socioeconomic status (SES) neighborhoods. After multivariable adjustment, we found approximately 3 times the odds of study participation among predominantly AA addresses in low vs. average SES neighborhoods (odds ratio (OR) = 3.06; 95% confidence interval (CI) = 2.20-4.24). Conversely, for non-AA addresses, we observed no difference in the odds of study participation in low vs. average SES neighborhoods (OR = 0.89; 95% CI = 0.69-1.14) after multivariable adjustment. Our findings suggest that AA participants in low SES neighborhoods may be recruited for bio-specimen research through door-to-door approaches with compensation. Future studies may elucidate best practices to improve bio-specimen research participation among minority populations.

2.
J Neurosurg Spine ; : 1-7, 2020 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-31952042

RESUMO

OBJECTIVE: Cervical disc replacement (CDR) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylotic pathology. While much is known about the efficacy of CDR within the constraints of a well-controlled, experimental setting, little is known about general utilization. The authors present an analysis of temporal and geographic trends in "real-world" utilization of CDR among those enrolled in private insurance plans in the US. METHODS: Eligible subjects were identified from the IBM MarketScan Databases between 2009 and 2017. Individuals 18 years and older, undergoing a single-level CDR or ACDF for cervical radiculopathy and/or myelopathy, were identified. US Census divisions were used to classify the region where surgery was performed. Two-level mixed-effects regression modeling was used to study regional differences in proportional utilization of CDR, while controlling for confounding by regional case-mix differences. RESULTS: A total of 47,387 subjects met the inclusion criteria; 3553 underwent CDR and 43,834 underwent ACDF. At a national level, the utilization of single-level CDR rose from 5.6 cases for every 100 ACDFs performed in 2009 to 28.8 cases per 100 ACDFs in 2017. The most substantial increases occurred from 2013 onward. The region of highest utilization was the Mountain region (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming), where 14.3 CDRs were performed for every 100 ACDFs (averaged over the 9-year period of study). This is in contrast to the East South Central region (Alabama, Kentucky, Mississippi, and Tennessee), where only 2.1 CDRs were performed for every 100 ACDFs. Patient factors that significantly increased the odds of undergoing a CDR were age younger than 40 years (OR 15.9 [95% CI 10.0-25.5]; p < 0.001), no clinical evidence of myelopathy/myeloradiculopathy (OR 1.5 [95% CI 1.4-1.7]; p < 0.001), and a Charlson Comorbidity Index score of 0 (OR 2.7 [95% CI 1.7-4.2]; p < 0.001). After controlling for these factors, significant differences in utilization rates remained between regions (chi-square test = 830.4; p < 0.001). CONCLUSIONS: This US national level study lends insight into the rate of uptake and geographic differences in utilization of the single-level CDR procedure. Further study will be needed to ascertain specific factors that predict adoption of this technology to explain observed geographic discrepancies.

3.
Cancer ; 126(2): 281-292, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31639217

RESUMO

BACKGROUND: Metastasectomy of isolated colorectal liver metastases (CRLM) requires significant clinical expertise and may not be readily available or offered. The authors hypothesized that hospitals that treat a greater percentage of patients from higher income catchment areas are more likely to perform metastasectomies regardless of patient or tumor characteristics. METHODS: Using the National Cancer Data Base, the authors classified facilities into facility income quartiles (FIQs) based on the percentage of patients from the wealthiest neighborhoods (by zip code). Quartile 1 included facilities with <2.1% of the patients residing within the highest income zip codes, quartile 2 included facilities with 2.2% to 15.6% of patients residing within the highest income zip codes, quartile 3 included facilities with 15.7% to 40.2% of patients residing within the highest income zip codes, and quartile 4 included facilities with 40.3% to 90.5% of patients residing within the highest income ZIP codes. Patient, tumor, and facility characteristics were analyzed using a multivariate logistic regression to identify associations between metastasectomy and FIQ. RESULTS: Patients with CRLM were more likely to undergo metastasectomy at facilities in the highest FIQ compared with the lowest FIQ (18% vs 11% in FIQ4; P = .001). This trend was not observed in the resection of primary tumors for nonmetastatic CRLM (rates of 95% vs 93%; P = .94). After adjusting for individual insurance status, distance traveled, zip code-level individual income, tumor, and host, patients who were treated at the highest FIQ facilities were found to be more likely to undergo metastasectomy (odds ratio, 1.29; 95% CI, 1.02-1.72 [P = .03]). CONCLUSIONS: Metastasectomy for CRLM is more likely to occur at facilities that serve a greater percentage of patients from high-income catchment areas, regardless of individual patient characteristics. This disparity uniquely affects those patients with advanced cancers for which specialized expertise for therapy is necessary.

4.
Medicine (Baltimore) ; 98(12): e14871, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30896632

RESUMO

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.


Assuntos
Estado Civil/estatística & dados numéricos , Medicare/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Modelos Logísticos , Masculino , Limitação da Mobilidade , Razão de Chances , Fatores Socioeconômicos , Estados Unidos
5.
Neurosurgery ; 84(2): 413-420, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29548034

RESUMO

BACKGROUND: Surgery for cervical radiculopathy is often approached by either anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). ACDF is more common; however, recent single center studies suggest comparable efficacy and significant cost savings with PCF in appropriately selected patients. OBJECTIVE: To compare utilization, adverse events, and costs for each approach from a national perspective. METHODS: Adults undergoing single level ACDF or PCF for cervical radiculopathy were included from a US commercial health insurance claims database spanning 2003 to 2014. Outcomes consisted of mortality, adverse events, length of stay, and total payments to the health provider. Propensity score matching balanced the groups on observed baseline covariates. RESULTS: The PCF cohort comprised 4851 subjects and the ACDF cohort included 46 147. A greater proportion of PCF cases were discharged on the same day (70.6% vs 46.1%; P < .001). Mortality (0.1/1000, P = .012), vascular injury (0.2/1000, P = .001), postoperative dysphagia/dysphonia (14.5/1000, P < .001), cutaneous cerebrospinal fluid leak (0.2/1000, P = .002), and deep venous thrombosis (0.9/1000, P = .013) occurred more frequency in the ACDF cohort. Conversely, wound infections (14.6/1000, P < .001) and 30-d readmissions (9.8/1000, P < .001) were more frequent in the PCF cohort. Mean unadjusted total payments for the PCF cohort were $15 281 ± 12 225 and $26 849 ± 16 309 for ACDF. Matched difference was -$11 726 [95% confidence interval: -$12 221, -$11 232, P < .001] favoring PCF. CONCLUSION: Within the inherent limitations of administrative data, our findings suggest an opportunity for value improvement in managing cervical radiculopathy and indicate a need for large-scale comparative study of clinical outcomes and costs.


Assuntos
Discotomia/métodos , Foraminotomia/métodos , Radiculopatia/cirurgia , Fusão Vertebral/métodos , Adulto , Vértebras Cervicais/cirurgia , Estudos de Coortes , Custos e Análise de Custo , Discotomia/efeitos adversos , Discotomia/economia , Feminino , Foraminotomia/efeitos adversos , Foraminotomia/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Resultado do Tratamento
6.
Neurosurg Clin N Am ; 29(1): 169-176, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29173430

RESUMO

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord impairment worldwide. Surgical intervention has been demonstrated to be effective and is becoming standard of care. Spine surgery, however, is costly and value needs to be demonstrated. This review serves to summarize the key health economic concepts as they relate to the assessment of the value of surgery for DCM. This is followed by a discussion of current health economic research on DCM, which suggests that surgery is likely to be cost effective. The review concludes with a summary of future questions that remain unanswered, such as which patient subgroups derive the most value from surgery and which surgical approaches are the most cost effective.


Assuntos
Descompressão Cirúrgica/economia , Espondilose/cirurgia , Análise Custo-Benefício , Custos de Cuidados de Saúde , Nível de Saúde , Humanos , Qualidade de Vida , Espondilose/economia
7.
Health Econ ; 27(1): e55-e70, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28726348

RESUMO

Access to cancer drugs used off-label is important to cancer patients but may drive up healthcare costs with little evidence of clinical benefit. We hypothesized that state health insurance mandates for private insurers to provide coverage for off-label use of cancer drugs cause higher rates of off-label use. We used Truven MarketScan data from 1999 to 2007 on utilization of 35 infused chemotherapy drugs in private health plans in the United States, covering the period when eight states implemented off-label coverage laws. We studied trends in off-label use of drugs, distinguishing between appropriate and inappropriate off-label use according to drug compendia, and estimated difference-in-difference regressions of the effect of state laws on off-label use. We estimate 41% of utilization was off-label, including 17% of use conservatively defined as inappropriate. Trends show gradual declines in off-label use over time. We also find no discernable effect of state laws mandating coverage of off-label use of cancer drugs on utilization patterns under multiple empirical specifications. Our conclusion is that policymakers should consider shifting away from mandating coverage as a way to ensure access to drugs off-label and towards incentivizing adherence to clinical practice guidelines to improve the quality and value of off-label use.


Assuntos
Antineoplásicos/uso terapêutico , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/legislação & jurisprudência , Neoplasias/tratamento farmacológico , Uso Off-Label/legislação & jurisprudência , Medicina Baseada em Evidências , Feminino , Custos de Cuidados de Saúde , Humanos , Cobertura do Seguro/economia , Masculino , Pessoa de Meia-Idade , Governo Estadual , Estados Unidos
8.
Med Care Res Rev ; : 1077558717739214, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29094651

RESUMO

Dramatic improvements in reported nursing home quality, including staffing ratios, have come under increased scrutiny in recent years because they are based on data self-reported by nursing homes. In contrast to other domains, the key mechanism for real improvement in the staffing ratios domain is clearer: to improve scores, nursing homes should increase staffing expenditures. We analyze the relationship between changes in expenditures and reported staffing quality pre- versus post the 5-star rating system. Our results show that the relationship between expenditures and licensed practical nurse staffing is weaker in the post-5-star period, overall, and across subgroups; furthermore, there is a weaker relationship between expenditures and registered nurse staffing among for-profit facilities with a high share of Medicaid residents in the post-5-star period. The weaker relationship between staffing expenditures and staffing scores in the post-5-star era underscores the potential for gaming of the self-reported staffing scores and the need for more reliable sources.

9.
J Clin Oncol ; 35(22): 2482-2489, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28471711

RESUMO

Purpose The high cost of oncology drugs threatens the affordability of cancer care. Previous research identified drivers of price growth of targeted oral anticancer medications (TOAMs) in private insurance plans and projected the impact of closing the coverage gap in Medicare Part D in 2020. This study examined trends in TOAM prices and patient out-of-pocket (OOP) payments in Medicare Part D and estimated the actual effects on patient OOP payments of partial filling of the coverage gap by 2012. Methods Using SEER linked to Medicare Part D, 2007 to 2012, we identified patients who take TOAMs via National Drug Codes in Part D claims. We calculated total drug costs (prices) and OOP payments per patient per month and compared their rates of inflation with general health care prices. Results The study cohort included 42,111 patients who received TOAMs between 2007 and 2012. Although the general prescription drug consumer price index grew at 3% per year over 2007 to 2012, mean TOAM prices increased by nearly 12% per year, reaching $7,719 per patient per month in 2012. Prices increased over time for newly and previously launched TOAMs. Mean patient OOP payments dropped by 4% per year over the study period, with a 40% drop among patients with a high financial burden in 2011, when the coverage gap began to close. Conclusion Rising TOAM prices threaten the financial relief patients have begun to experience under closure of the coverage gap in Medicare Part D. Policymakers should explore methods of harnessing the surge of novel TOAMs to increase price competition for Medicare beneficiaries.


Assuntos
Antineoplásicos/economia , Efeitos Psicossociais da Doença , Medicare Part D , Terapia de Alvo Molecular/economia , Neoplasias/tratamento farmacológico , Neoplasias/economia , Honorários por Prescrição de Medicamentos/estatística & dados numéricos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/administração & dosagem , Comércio/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Honorários por Prescrição de Medicamentos/tendências , Estados Unidos
10.
Spine J ; 17(1): 15-25, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27793760

RESUMO

BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) represents the most common cause of non-traumatic spinal cord impairment in adults. Surgery has been shown to improve neurologic symptoms and functional status, but it is costly. As sustainability concerns in the field of health care rise, the value of care has come to the forefront of policy decision-making. Evidence for both health-related quality of life outcomes and financial expenditures is needed to inform resource allocation decisions. PURPOSE: This study aimed to estimate the lifetime incremental cost-utility of surgical treatment for DCM. DESIGN/SETTING: This is a prospective observational cohort study at a Canadian tertiary care facility. PATIENT SAMPLE: We recruited all patients undergoing surgery for DCM at a single center between 2005 and 2011 who were enrolled in either the AOSpine Cervical Spondylotic Myelopathy (CSM)-North America study or the AOSpine CSM-International study. OUTCOME MEASURES: Health utility was measured at baseline and at 6, 12, and 24 months following surgery using the Short Form-6D (SF-6D) health utility score. Resource expenditures were calculated on an individual level, from the hospital payer perspective over the 24-month follow-up period. All costs were obtained from a micro-cost database maintained by the institutional finance department and reported in Canadian dollars, inflated to January 2015 values. METHODS: Quality-adjusted life year (QALY) gains for the study period were determined using an area under the curve calculation with a linear interpolation estimate. Lifetime incremental cost-to-utility ratios (ICUR) for surgery were estimated using a Markov state transition model. Structural uncertainty arising from lifetime extrapolation and the single-arm cohort design of the study were accounted for by constructing two models. The first included a highly conservative assumption that individuals undergoing nonoperative management would not experience any lifetime neurologic decline. This constraint was relaxed in the second model to permit more general parameters based on the established natural history. Deterministic and probabilistic sensitivity analyses were employed to account for parameter uncertainty. All QALY gains and costs were discounted at a base of 3% per annum. Statistical significance was set at the .05 level. RESULTS: The analysis included 171 patients; follow-up was 96.5%. Mean age was 58.2±12.0 years and baseline health utility was 0.56±0.14. Mean QALY gained over the 24-month study period was 0.139 (95% confidence interval: 0.109-0.170, p<.001) and the mean 2-year cost of treatment was $19,217.82±12,404.23. Cost associated with the operation comprised 65.7% of the total. The remainder was apportioned over presurgical preparation and postsurgical recovery. Three patients required a reoperation over the 2-year follow-up period. The costs of revision surgery represented 1.85% of the total costs. Using the conservative model structure, the estimated lifetime ICUR of surgical intervention was $20,547.84/QALY gained, with 94.7% of estimates falling within the World Health Organization definition of "very cost-effective" ($54,000 CAD). Using the more general model structure, the estimated lifetime ICUR of surgical intervention was $11,496.02/QALY gained, with 97.9% of estimates meeting the criteria to be considered "very cost-effective." CONCLUSIONS: Surgery for DCM is associated with a significant quality of life improvement. The intervention is cost-effective and, from the perspective of the hospital payer, should be supported.


Assuntos
Vértebras Cervicais/cirurgia , Análise Custo-Benefício , Procedimentos Neurocirúrgicos/economia , Assistência Centrada no Paciente/economia , Qualidade de Vida , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação/economia , Doenças da Medula Espinal/economia , Doenças da Medula Espinal/cirurgia
12.
Health Econ ; 25(6): 723-39, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-25845858

RESUMO

Financial relationships between physicians and industry are vital to biomedical innovation yet create the potential for conflicts of interest in medical practice. I consider an inducement model of the role of financial relationships in health care markets, where consulting payments induce physicians to use more devices of the firms that sponsor them. To test the model, I exploit a policy shock, whereby government monitoring of payments to joint replacement surgeons resulted in declines of over 60% in both total payments and in the number of physicians receiving payments from 2007 to 2008. Using hospital discharge data from three states, I find that the loss of payments leads physicians to switch 7 percentage points of their device utilization from their sponsoring firms' devices to other firms' devices, an effect which is concentrated among surgeons with low switching costs. These results offer support for the inducement model. I also find evidence of an increase in medical productivity following the policy intervention, which suggests conditions under which regulation of financial relationships would be socially beneficial. Copyright © 2015 John Wiley & Sons, Ltd.


Assuntos
Conflito de Interesses/economia , Setor de Assistência à Saúde/economia , Procedimentos Ortopédicos/economia , Artroplastia de Substituição/economia , Humanos , Indústrias/economia , Próteses e Implantes/economia , Encaminhamento e Consulta/economia , Cirurgiões/economia
13.
Neurosurg Focus ; 39(6): E6, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26621420

RESUMO

OBJECT Neurosurgery studies traditionally have evaluated the effects of interventions on health care outcomes by studying overall changes in measured outcomes over time. Yet, this type of linear analysis is limited due to lack of consideration of the trend's effects both pre- and postintervention and the potential for confounding influences. The aim of this study was to illustrate interrupted time-series analysis (ITSA) as applied to an example in the neurosurgical literature and highlight ITSA's potential for future applications. METHODS The methods used in previous neurosurgical studies were analyzed and then compared with the methodology of ITSA. RESULTS The ITSA method was identified in the neurosurgical literature as an important technique for isolating the effect of an intervention (such as a policy change or a quality and safety initiative) on a health outcome independent of other factors driving trends in the outcome. The authors determined that ITSA allows for analysis of the intervention's immediate impact on outcome level and on subsequent trends and enables a more careful measure of the causal effects of interventions on health care outcomes. CONCLUSIONS ITSA represents a significant improvement over traditional observational study designs in quantifying the impact of an intervention. ITSA is a useful statistical procedure to understand, consider, and implement as the field of neurosurgery evolves in sophistication in big-data analytics, economics, and health services research.


Assuntos
Neurocirurgia , Procedimentos Neurocirúrgicos , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Neurocirurgia/métodos , Neurocirurgia/normas , Neurocirurgia/tendências , Melhoria de Qualidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Compressão da Medula Espinal/cirurgia , Fatores de Tempo
14.
J Clin Oncol ; 33(19): 2190-6, 2015 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-25987701

RESUMO

PURPOSE: This study sought to define and identify drivers of trends in cost and use of targeted therapeutics among privately insured nonelderly patients with cancer receiving chemotherapy between 2001 and 2011. METHODS: We classified oncology drugs as targeted oral anticancer medications, targeted intravenous anticancer medications, and all others. Using the LifeLink Health Plan Claims Database, we studied and disaggregated trends in use and in insurance and out-of-pocket payments per patient per month and during the first year of chemotherapy. RESULTS: We found a large increase in the use of targeted intravenous anticancer medications and a gradual increase in targeted oral anticancer medications; targeted therapies accounted for 63% of all chemotherapy expenditures in 2011. Insurance payments per patient per month and in the first year of chemotherapy for targeted oral anticancer medications more than doubled in 10 years, surpassing payments for targeted intravenous anticancer medications, which remained fairly constant throughout. Substitution toward targeted therapies and growth in drug prices both at launch and postlaunch contributed to payer spending growth. Out-of-pocket spending for targeted oral anticancer medications was ≤ half of the amount for targeted intravenous anticancer medications. CONCLUSION: Targeted therapies now dominate anticancer drug spending. More aggressive management of pharmacy benefits for targeted oral anticancer medications and payment reform for injectable drugs hold promise. Restraining the rapid rise in spending will require more than current oral drug parity laws, such as value-based insurance that makes the benefits and costs transparent and involves the patient directly in the choice of treatment.


Assuntos
Antineoplásicos/economia , Custos de Medicamentos/estatística & dados numéricos , Seguro de Serviços Farmacêuticos/economia , Neoplasias/tratamento farmacológico , Adulto , Antineoplásicos/administração & dosagem , Antineoplásicos/uso terapêutico , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
15.
Hum Vaccin Immunother ; 10(11): 3415-24, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25483656

RESUMO

Cancer immunotherapy is a rapidly growing field in oncology. One attractive feature of cancer immunotherapy is the purported combination of minimal toxicity and durable responses. However such treatments are often very expensive. Given the wide-spread concern over rising health care costs, it is important for all stakeholders to be well-informed on the cost and cost-effectiveness of cancer immunotherapies. We performed a comprehensive literature review of cost and cost-effectiveness research on therapeutic cancer vaccines and monoclonal antibodies, to better understand the economic impacts of these treatments. We summarized our literature searches into three tables by types of papers: systematic review of economic studies of a specific agent, cost and cost-effectiveness analysis. Our review showed that out of the sixteen immunotherapy agents approved, nine had relevant published economic studies. Five out of the nine studied immunotherapy agents had been covered in systematic reviews. Among those, only one (rituximab for non-Hodgkin lymphoma) was found to be cost-effective. Of the four immunotherapy drugs not covered in systematic reviews (alemtuzumab, ipilimumab, sipuleucel-T, ofatumumab), high incremental cost-effectiveness ratio (ICER) was reported for each. Many immunotherapies have not had economic evaluations, and those that have been studied show high ICERs or frank lack of cost-effectiveness. One major hurdle in improving the cost-effectiveness of cancer immunotherapies is to identify predictive biomarkers for selecting appropriate patients as recipients of these expensive therapies. We discuss the implications surrounding the economic factors involved in cancer immunotherapies and suggest that further research on cost and cost-effectiveness of newer cancer vaccines and immunotherapies are warranted as this is a rapidly growing field with many new drugs on the horizon.


Assuntos
Anticorpos Monoclonais/economia , Anticorpos Monoclonais/uso terapêutico , Vacinas Anticâncer/economia , Vacinas Anticâncer/uso terapêutico , Imunoterapia/economia , Análise Custo-Benefício , Citocinas/uso terapêutico , Humanos , Imunoterapia/métodos , Neoplasias/terapia
16.
J Med Screen ; 21(4): 207-15, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25118160

RESUMO

BACKGROUND: Newly released United States Preventive Services Task Force (USPSTF) recommendations for lung cancer screening are expected to increase demand for low-dose computed tomography scanning, but health system capacity constraints might threaten the scale-up of screening. OBJECTIVES: To estimate the prevalence of capacity constraints in the radiologist workforce and resulting potential disparities in access to lung cancer screening. METHODS: We combined information from health interview surveys to estimate the numbers of smokers who meet the USPSTF eligibility criteria, and information from administrative datasets to estimate the numbers of radiologists and the numbers of scans they currently interpret in Health Service Areas (HSAs) nationwide. We estimated and mapped the prevalence of capacity constrained HSAs - those having a greater than 5% or greater than 25% projected increase in scans over current levels from scaling up screening - and used descriptive statistics and logistic regressions to identify HSA characteristics associated with capacity constraints. RESULTS: Scaling up lung cancer screening would increase imaging procedures by an average of 4% across HSAs. Of the 9.6 million eligible smokers, 1,023,943 lived in HSAs with increases of at least 5%. HSAs that were rural, with many eligible smokers, and disproportionately Hispanic or low-income smokers had significantly higher odds of facing capacity constraints. CONCLUSIONS: Disparities in access to lung cancer screening appear likely unless policy makers target HSAs with few radiologists for additional resources. Radiologists should be able to absorb the workload imposed by lung cancer screening in most areas of the country.


Assuntos
Detecção Precoce de Câncer/estatística & dados numéricos , Neoplasias Pulmonares/diagnóstico por imagem , Médicos/provisão & distribução , Radiologia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Recursos Humanos , Carga de Trabalho
17.
J Am Coll Surg ; 219(3): 525-33.e1, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25026873

RESUMO

BACKGROUND: Vertebroplasty and kyphoplasty are procedures for treating vertebral compression fractures (VCFs). In August 2009, 2 randomized trials in the New England Journal of Medicine found that vertebroplasty did not reduce pain or disability relative to a sham procedure among patients with osteoporotic VCFs. STUDY DESIGN: We evaluated quarterly trends in per capita rates of vertebroplasties and kyphoplasties using the Florida hospital inpatient discharge and ambulatory surgery center databases from 2005 to 2012, supplemented with physician specialty and population data. We reported trends by procedure type, patient diagnosis, and physician specialty. We modeled the procedures as interrupted time series with a break when the clinical trials were published, and estimated changes in procedure rates and health expenditures resulting from the trials. RESULTS: The trials led to a 51.5% decline in the per capita vertebroplasty rate and a 40.0% decline in the kyphoplasty rate (both results p < 0.010) compared with what procedure rates would have been without the trials. Vertebroplasty rates for interventional radiologists displayed no significant change; rates for surgeons and other specialists declined by 73.1% (p < 0.010). Overall, these changes imply nationwide health expenditure savings of just over $1 billion per year. CONCLUSIONS: Publication of negative clinical trial results led to moderate reductions in vertebroplasties and kyphoplasties for osteoporotic VCFs. However, vertebroplasty and kyphoplasty continue to be widely used to treat patients with osteoarthritis. Substantial differences in response across physicians suggest an important role for specialty society clinical guidelines in modulating how clinical evidence is incorporated into routine practice.


Assuntos
Fraturas por Compressão/cirurgia , Editoração , Fraturas da Coluna Vertebral/cirurgia , Vertebroplastia/estatística & dados numéricos , Idoso , Feminino , Humanos , Cifoplastia/estatística & dados numéricos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Falha de Tratamento
18.
Pharmacoeconomics ; 32(7): 651-80, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24821281

RESUMO

BACKGROUND: Over the last 15 years, a paradigm shift in oncology has led to the approval of dozens of targeted oral anti-cancer medications (OAMs), which have become the standard of care for certain cancers. While more convenient for patients than infused drugs, the possibility of non-adherence and the frequently high costs of targeted OAMs have proven controversial. OBJECTIVE: Our objective was to perform the first comprehensive review of cost-effectiveness analyses (CEAs) of targeted OAMs. METHODS: A literature search in PubMed, The Cochrane Library, and the Health Technology Assessment (HTA) reports published by the National Institute for Health Research HTA Programme in the UK was performed, covering articles published in the 5 years prior to 30 September 2013. Our inclusion criteria were peer-reviewed English-language full-text original research articles with a primary focus on CEA related to targeted OAMs. We categorized these articles by treatment setting (i.e. cancer site/type, line of therapy, and treatment and comparator) and synthesized information from the articles into summary tables. RESULTS: We identified 41 CEAs covering nine of the 18 targeted OAMs approved by the US FDA as of December 2012. These medications were studied in seven cancers, most often as second-line therapy for advanced-stage patients. In over half of treatment settings where a targeted OAM was compared with treatment that was not a targeted OAM, targeted OAMs were considered cost effective. Limitations in interpreting these findings include the risk of bias due to author conflicts of interest, cross-country variation, and difficulties in generalizing clinical trial evidence to community practice. CONCLUSIONS: Several types of cost-effectiveness studies remain under-represented in the literature on targeted OAMs, including those for follow-on indications approved after the initial indication for a drug and for off-label indications, head-to-head comparisons of targeted OAMs with other targeted OAMs and targeted intravenous therapies, and studies that adopt a perspective other than the payer's. Keeping up with the increasing number of approved targeted OAMs will also prove an important challenge for economic evaluation.


Assuntos
Antineoplásicos/administração & dosagem , Antineoplásicos/economia , Custos de Medicamentos , Terapia de Alvo Molecular/economia , Neoplasias/tratamento farmacológico , Administração Oral , Antineoplásicos/uso terapêutico , Análise Custo-Benefício , Humanos , Terapia de Alvo Molecular/métodos , Neoplasias/economia , Neoplasias/metabolismo
19.
Breast Cancer Res Treat ; 144(2): 417-25, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24557339

RESUMO

Trastuzumab, although cardiotoxic, is associated with improved survival in HER2-positive breast cancer. Non-compliance with HER2 testing guidelines before prescribing trastuzumab occurs in practice; however, the clinical consequences are unclear. Using SEER-Medicare database (2000-2009), we assessed differences in baseline characteristics between women ≥ 65 with breast cancer who received and did not receive HER2 testing prior to trastuzumab prescription. We used propensity score matched-pair analysis to balance the confounders between these two groups. We assessed the differences in overall survival and 3-year rates of avoiding congestive heart failure (CHF) between women who received trastuzumab without HER2 testing (trastuzumab group) and women who had chemotherapy but did not receive trastuzumab (irrespective of testing) (chemo-only group). Based on the matched data, we used Cox regression in these assessments with double robust estimation or with stratification. Among women who received trastuzumab, 140 (4.7 %) had no documentation of HER2 testing. Breast surgery, south residential region, and an earlier year of diagnosis were predictive of no HER2 testing in multivariate logistic regression. Women in the chemo-only group had similar overall survival (HR = 1.28; P = 0.108) over an 8-year follow-up post-diagnosis and significantly higher likelihood of avoiding CHF over 3 years after the first administration of chemotherapy or trastuzumab (HR = 1.66, P = 0.036) compared to women in the trastuzumab group, using the propensity score-matched data. Non-evidence-based prescription of trastuzumab is associated with increased rates of CHF with no additional survival benefit among older women with breast cancer. Inappropriate prescriptions of targeted therapies agent can lead to detrimental health and financial consequences.


Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Antineoplásicos/efeitos adversos , Neoplasias da Mama/tratamento farmacológico , Fatores Etários , Idoso , Neoplasias da Mama/metabolismo , Quimioterapia Adjuvante/métodos , Feminino , Humanos , Receptor ErbB-2/metabolismo , Trastuzumab
20.
Expert Rev Pharmacoecon Outcomes Res ; 14(1): 45-69, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24378038

RESUMO

There has been a rapid increase in the use of targeted oral anticancer medications (OAMs) in the past decade. As OAMs are often expensive, economic consideration play a significant role in the decision to prescribe, receive or cover them. This paper performs a systematic review of costs or budgetary impact of targeted OAMs to better understand their economic impact on the healthcare system, patients as well as payers. We present our review in a summary table that describes the method and main findings, take into account multiple factors, such as country, analytical approach, cost type, study perspective, timeframe, data sources, study population and care setting when we interpret the results from different papers, and discuss the policy and clinical implications. Our review raises a concern regarding the role of sponsorship on findings of economic analyses as the vast majority of pharmaceutical company-sponsored studies reported cost advantages toward the sponsor's drugs.


Assuntos
Antineoplásicos/uso terapêutico , Sistemas de Liberação de Medicamentos , Neoplasias/tratamento farmacológico , Administração Oral , Antineoplásicos/administração & dosagem , Antineoplásicos/economia , Análise Custo-Benefício , Tomada de Decisões , Assistência à Saúde/economia , Indústria Farmacêutica/economia , Humanos , Neoplasias/economia , Apoio à Pesquisa como Assunto/economia
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