Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial

STUDY OBJECTIVE

We determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.

METHODS

Emergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.

RESULTS

There were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.

CONCLUSION

Compared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.

Pattern of mortality in a sample of Maryland residents with severe mental illness

In a cohort of Maryland Medicaid recipients with severe mental illness followed from 1993-2001, we compared mortality with rates in the Maryland general population including race and gender subgroups. Persons with severe mental illness died at a mean age of 51.8 years, with a standardized mortality ratio of 3.7 (95%CI, 3.6-3.7).

The biology and prognostic value of lymphatic vessel density (LD) and lymphatic invasion (LI) in regression in melanoma

9017

Background: Regression in melanoma is characterized by increased vascularity, lymphocytic infiltrate and fibroplasia in the papillary dermis, accompanied by the absence (complete regression, CoR) or presence (partial regression, PaR) of melanoma cells in the epidermis. The prognostic value of regression is controversial. We noticed that LD and LI were increased in the areas of regression (AR) or areas with brisk lymphocytic infiltration (AB). Our goal was to clarify the prognostic value of regression in melanoma. Methods: Dual immunohistochemical staining was done using antibodies to podoplanin (lymphatic vessels) and S100 (melanoma cells) on paraffin tissues from 321 patients with vertical growth phase (VGP) primary melanomas who had 10 years or more of follow-up. LD in AR (both CoR and PaR) was compared with that of normal dermis adjacent and distant, as well as LD in the AB. LI in these areas was also scored. Unadjusted and adjusted hazard rates were obtained from univariate and multivariate Cox models for time to melanoma-specific death using established melanoma prognostic factors. Results: 116 patients (36%) had regression: 75 CoR (23%) and 41 PaR (13%). LD significantly decreased stepwise from CoR (mean ± se, 23.7 ± 2.7) to PaR (15.5 ± 1.1), adjacent normal dermis (7.3 ± 0.28) and distant normal dermis (5.4±0.31) and it was significantly elevated in the AB (18.5±0.78). Melanomas with CoR had the highest percentage of LI in both AR and AB. In addition, the percentage of LI in AB was highest for men and for those with VGP tumor infiltrating lymphocytes (TILs). Both high LD in AR and more LI in AB were associated with poor prognosis (p=0.004 and p=0.002, respectively). Six factors were significant in the final multivariate model: LI in AB (HR=2.3), LD in AR (HR=1.04), thickness (HR=1.44), axial (HR=7.7), ulceration (HR=2.5) and no VGP TILs (HR=2.8). Conclusions: AR and AB were associated with increased LD and higher incidence of LI in primary melanomas. LD and LI in AR or AB are independent prognostic factors. Our data suggest that the effects of regression on prognosis are mediated at least in part through lymphangiogenesis and LI.

No significant financial relationships to disclose.

The relationship between adherence to adjuvant hormonal therapy and survival among low-income, insured women with primary breast cancer

e11522

Background: Clinical trials and meta-analyses show that adjuvant hormonal therapy for hormone receptor positive breast cancer significantly decreases risk of death. We explored the relationship between adherence to adjuvant hormonal therapy and death in a low-income, Medicaid-insured population. Methods: Using a Medicaid claims-tumor registry linked database and National Death Index data (NDI), we evaluated adherence to adjuvant hormonal therapy [defined as >80% Medication Possession Ratio (MPR)] and mean six-year overall and cancer-specific survival by local versus regional stage for all female breast cancer diagnosed in years 2000–2002, in North Carolina. The Kaplan-Meier and Cox Proportional Hazards models were used to determine the role of adherence on cancer-specific survival. Models were adjusted for age, race, Charlson comorbidity score, number of prescription medications, type of surgery, use of radiation therapy, prior chemotherapy, hormone receptor status (positive or unknown). Results: The final sample consisted of 1,042 cases [ages range 29–97 years (mean 65.9 years; 56% Caucasian; mean Charlson comorbidity score 4.1 (SD 2.9); 680 local and 362 regional stage], of which 732 filled a prescription for adjuvant hormonal therapy within the year after breast cancer diagnosis. Filling a prescription for adjuvant hormonal therapy, versus not, was not significantly associated with cancer-related death: HR 1.04 (95% CI 0.66 - 1.64) overall; HR 0.75 (95% CI 0.39 - 1.43) for local stage and HR 1.01 (95% CI 0.51 - 2.00) for regional stage. However, adherence in the highest quartile (MPR>95) is associated with an increase in mortality risk. Conclusions: In this low income insured group of breast cancer patients, no statistically significant association was found between death rates and use of adjuvant hormonal therapy. However, an unexpected association between very high adherence and increase in mortality was found. This may reflect methodological limitations of claims data involving bias and unidentified patient risk. More research is needed to explore reasons for higher mortality among low-income women with high medication adherence.

[Table: see text]

Prognostic risk group classification for patients (pts.) with platinum-refractory metastatic urothelial cancer (UC) treated with second-line chemotherapy

5078

Background: Second-line chemotherapy in pts. with platinum-refractory metastatic UC is associated with low objective response rates and short progression-free and overall survival. Prognostic risk groups in this setting have not been reported. Methods: We studied 151 pts. with platinum-refractory metastatic UC treated with second-line vinflunine (VFL) (Vaughn, GU Cancer Symposium. 2008). Using progression at 6 months as the primary endpoint, baseline patient characteristics were examined in univariate and multivariate analyses. Multivariate logistic regression was used to identify independent predictors of progression at 6 months, and the variable selection result was validated by nonparametric bootstrap. Risk scores were generated from summing the relative importance of the factors identified on multivariate analysis. Patients were classified into risk groups and compared. Results: Of the 151 pts., 80% were male, 54% were aged > 65 years, and 68% had Karnofsky performance status (KPS) > 90%. 115 pts. (76%) progressed or died by 6 months after initiating VFL. The factors associated with an increased odds ratio (OR) for disease progression at 6 months were presence of visceral metastases (OR 8.08; p < 0.001; 2 points), KPS < 90% (OR 6.63; p = 0.002; 2 points), and age < 65 years (OR 3.53; p = 0.008; 1 point). Only 41% of the low-risk group (score 0–1) progressed by 6 months compared to 74% of the intermediate-risk group (score 2) and 91% of the high-risk group (score 3–5). Compared to the low-risk group, the intermediate-risk group had OR for disease progression at 6 months of 4.01 (p = 0.006) and the high-risk group had OR of 15.5 (p < 0.001). Conclusions: We identified risk factors and developed a scoring system that classifies pts. with platinum-refractory UC treated with second-line chemotherapy into risk groups based upon probability of disease progression at 6 months. Similar to the first-line setting, the presence of visceral metastases and decreased KPS predict a worse prognosis. This system should be validated in other independent populations.

[Table: see text]

Ki67 as a prognostic biomarker for patients with vertical growth phase (VGP) melanomas

9043

Background: In VGP melanomas proliferation is reflected in dermal mitotic figures (“mitogenic” VGP) and/or tumor cell nests larger than any epidermal nest. An alternative to mitotic rate (MR) to characterize cell proliferation is the expression of Ki67 protein. Since Ki67 is expressed in all phases of the cell cycle except G0, it is potentially a more robust biomarker for proliferation and prognosis than mitoses. Methods: To test the hypothesis that Ki67 would replace MR as a prognostic factor, we did a retrospective cohort study of 432 patients with Stage I/II primary VGP melanomas who had at least 10 years of follow up. Tissue sections were stained using the monoclonal antibody MIB-1 to Ki67 and the % of positive melanoma cells were evaluated by two readers. ROC curves for Ki67 and MR were computed. Predicted probabilities (PP) of 10-year melanoma-specific death were computed from 3 multivariate logistic regression models, one for each biomarker (Models 1 and 2) and one with both (Model 3), controlling for established melanoma prognostic factors (thickness, gender, anatomic site, ulceration, regression and tumor infiltrating lymphocytes), and compared. Cross-validation was used to assess differences between using Ki67 and using MR including the differences in PP, Brier scores and the misclassification rates. A decision curve analysis was done to assess the clinical net benefit of the two. Results: The areas under the ROC curve (AUCs) for Ki67 and MR, both continuous factors, were 0.69 and 0.79, respectively. In the multivariate analysis, Ki67 expression was significant in Model 1 (OR=1.03, 95% CI: 1.01–1.05), mitotic rate was not significant in Model 2 (1.05, 0.99–1.1), and only Ki67 was significant in Model 3 (1.03, 1.01–1.05). The AUCs for the three models were 0.84, 0.84, and 0.85, respectively. Based on cross-validation, there was no difference between the two biomarkers in PP, Brier scores, or misclassification rates. The decision cost analysis demonstrated the same net benefit for the two. Conclusions: A prospective study needs to be conducted to confirm that Ki67 and MR are equivalent.

No significant financial relationships to disclose.

The prognostic significance of lymphatic invasion in primary melanoma

9050

Background: Lymphatic invasion (LI) is an under-observed phenomenon in primary malignancies that can be better detected by immunostaining and that may associate with prognosis. In this study we sought to test the hypothesis that LI was associated with melanoma-specific survival (MSS) and was an independent prognostic factor. Methods: This study included 277 patients with stage I/II melanomas in vertical growth phase (VGP) who had at least 10 years of follow up. The log-rank test was used to test the study hypothesis - 72 melanoma-specific deaths were needed for 80% power to detect an odds ratio of 2.1. Paraffin sections were stained with antibodies to podoplanin (lymphatic vessels) and S-100 (melanoma cells) to identify LI. Univariate and multivariate Cox models were used to evaluate the prognostic significance of LI. An independent cohort of 106 similar patients was used for validation of the 10-year MSS rates. Results: LI was observed in 44.5% (95% CI: 38.6% - 50.4%) of the melanomas and its presence was significantly associated with thickness, mitotic rate, gender, age, and ulceration (U). The Kaplan-Meier survival curves for those with and without LI were significantly different (log-rank test p=0.022). The final multivariate model for time to MSD identified 4 independent prognostic factors: thickness (HR=1.5, p<0.001), U (HR=2.2 p=0.013), site (HR=3.9, p<0.001) and LI (HR=1.9, p=0.015). These factors were used to define a prognostic tree with 5 risk groups defined by melanomas that were thin (≤1.0mm) with no LI or U; thin with LI but no U; 1–3mm with no U; 1–3mm with U; and >3mm. Respectively, MSS rates were 100%, 88.6%, 77%, 48% and 42%. In the validation set, observed 10-year MSS rates in each risk group were not significantly different from those predicted from the survival curves for the tree-based risk groups. Conclusions: LI is an independent prognostic factor for MSS. Among patients with thin melanomas without U the 10-year MSS was lower for those patients with LI (89%, 95% CI=78% - 99%; n=41) compared to those without (100%, n=78). LI is an important prognostic factor that needs further validation in a population of patients from the sentinel node biopsy era.

No significant financial relationships to disclose.

Rising out-of-pocket spending for chronic conditions: a ten-year trend

We examined the prevalence of self-reported chronic conditions and out-of-pocket spending using the 2005 Medical Expenditure Panel Survey (MEPS) and made comparisons to previously published MEPS data. Our study found that the prevalence of self-reported chronic conditions is increasing among not only the old-old but also people in midlife and earlier old age. The greatest growth occurred in the number of people affected by multiple chronic diseases, a group with sizable out-of-pocket spending. Policymakers should be aware that cost sharing at the point of care can disproportionately burden people with chronic conditions and discourage adherence to drugs that prevent disease progression.

Adjuvant hormonal therapy use among insured, low-income women with breast cancer

PURPOSE Use of adjuvant hormonal therapy, which significantly decreases breast cancer mortality, has not been well described among poor women, who are at higher risk of cancer-related death. Here we explore use of adjuvant hormonal therapy in an insured, low-income population. METHODS A North Carolina Cancer Registry-Medicaid linked data set was used. Women with hormone receptor-positive or unknown, nonmetastatic breast cancer, diagnosed between 1998 and 2002, were included. Main outcomes were (1) prescription fill within 1 year of diagnosis, (2) adherence (medication possession ratio), and (3) persistence (absence of a 90-day gap in prescription fills over 12 months). Results The population consisted of 1,491 women (mean age, 67 years). Sixty-four percent filled prescriptions. Predictors of prescription fill included the following: older age (odds ratio [OR], 1.01; P = .017), greater number of prescription medications (OR, 1.06; P < .001), nonmarried status (OR, 1.82; P = .001), higher stage (OR, 1.83; P < .001), positive hormone receptor status (positive v unknown, OR, 1.98; P < .001), not receiving adjuvant chemotherapy (OR, 1.74; P = .001), receipt of adjuvant radiation (OR, 1.55; P = .004), and treatment in a small hospital (OR, 1.49; P = .024). Adherence and persistence rates were 60% and 80%, respectively. Nonmarried status predicted greater adherence (OR, 1.90; P = .006) and persistence (OR, 1.75; P = .031). CONCLUSION Prescription fill, adherence, and persistence to adjuvant hormonal therapy among socioeconomically disadvantaged women are low. Improving use of adjuvant hormonal therapy may lead to lower breast cancer-specific mortality in this population.

Paradoxical effects of cost reduction measures in managed care systems for treatment of severe psoriasis

BACKGROUND

Insurance companies vary widely in their coverage policies for severe psoriasis therapies. Unfortunately, coverage policies for psoriasis therapies do not necessarily follow current treatment paradigms, such that more expensive second or third line treatments may be more easily obtained than first line treatments.

METHODS

We reviewed insurance policy bulletins, statements of coverage/medical necessity, and prior authorization forms for three large insurance carriers regarding psoriasis treatment with biologic agents and phototherapy. A cost comparison was performed to estimate total costs to patients and insurer under the current system as well as a hypothetical system in which co-pays and deductibles are eliminated. Additionally, we reviewed the total cost to an insurer for placing a patient on a trial of home phototherapy before approving use of expensive biologics.

RESULTS

Requirements for coverage for phototherapy treatments are often the same, if not more stringent, than those for biologics. On an annual per patient basis, insurance companies pay an estimated $5, $76, and $23,408 for home phototherapy, office phototherapy, and biologics, respectively. The first year cost to patients, however, is estimated to be $2,590, $3,040, and $920 for home phototherapy, office phototherapy, and biologics, respectively. An initial 3-month trial of home phototherapy yields a graded annual cost savings to insurers of $21,610 to $2,110 per patient.

DISCUSSION

The evolution of psoriasis treatment has resulted in a paradoxical situation in which the use of lower-cost psoriasis treatments, with longer safety track records, is discouraged relative to newer options. If co-pays, deductibles, and prior authorization requirements that discourage phototherapy were reduced or eliminated, more patients and physicians would likely choose phototherapy over biologics. This has the potential to reduce overall healthcare costs for psoriasis management.

Comparison of iridium implant boost versus electron boost as a component of breast conservation treatment for early-stage breast carcinoma

Abstract #5144

Background: Breast conservation treatment includes lumpectomy followed by definitive radiation therapy, with radiation delivered to the whole breast followed by tumor bed boost. Currently, the boost is typically delivered by electron beams, but was previously delivered by iridium-192 implants. With re-emergence of implant radiotherapy techniques in current practice, long-term outcomes of both boost techniques are important.&#x2028; Methods: From 1977 to 1983, 141 patients with early-stage breast cancer were treated with iridium-192 boost after whole breast radiation. These patients were matched 1:1 to 141 patients who received electron boost from 1980 to 1990. Most implant patients were treated before widespread electron availability. Matching criteria included age at diagnosis, final pathologic margin status, pathologic tumor stage, and pathologic nodal stage. All patients had AJCC Stage I or II invasive breast carcinoma, had surgical excision of the primary tumor, and underwent definitive radiation to at least 60 grays. Chemotherapy was administered to 30 implant patients and 41 electron patients (p=0.014), and hormonal treatment to 3 implant patients and 12 electron patients (p=0.032). These systemic treatment variations were expected due to treatment era differences. Median follow-up was 16.7 years for implant patients (range 0.7-28.5) and 12.6 years for electron patients (range 1.4-25.4) (p&lt;0.001).&#x2028; Results: Electron boost patients were more likely to have excellent/good cosmesis versus fair/poor cosmesis than implant boost patients. At 1-year follow-up, this was significant (p=0.014). This trend continued, with odds ratio of having excellent/good cosmesis versus fair/poor cosmesis in implant patients compared to electron patients being 0.29 after 5 years (95% CI 0.027-1.38, p=0.114) and 0.24 after 10 years (95% CI 0.005-1.93, p=0.266).&#x2028; Incidence of all complications evaluated did not differ between the two groups (all p≥0.07). Incidence of breast fibrosis was 3% per year in implant patients and 4% per year in electron patients (p=0.17). In total, breast fibrosis developed in 41% of implant patients and 16% of electron patients. Incidence of infection was 14% per year in the implant group and 6% per year in the electron group (p=0.09). In total, infection developed in 7% of implant patients and 9% of electron patients. Incidence of rib fracture was 2% per year in both groups (p=0.8). Incidence of cardiopulmonary complications was 4% per year in implant patients and 3% per year in electron patients (p=0.7). Incidence of non-cardiac vascular complications was 4% per year in both groups (p=0.1). Incidence of neuropathy was 4% per year in implant patients and 1% per year in electron patients (p=0.07).&#x2028; Conclusions: Patients treated with electron boost were more likely than those treated with implant boost to have excellent/good cosmesis, though this observation did not reach statistical significance at 5- and 10-year follow-up. Complication rates did not differ significantly between the groups with long-term follow-up.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5144.

Patterns of use of vascular catheters for hemodialysis in children in the United States

BACKGROUND

Arteriovenous fistulas (AVFs) and grafts (AVGs) have been associated with improved clinical outcomes in children and adults with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) therapy, but use of vascular catheters is high. Identifying the reasons for the high prevalence of vascular catheters in children on HD therapy is necessary to assess whether targeted interventions may increase the prevalence of AVFs/AVGs.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Children younger than 18 years on HD therapy in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) Projects followed up in the US Renal Data System transplant files through December 31, 2004.

PREDICTOR

Vascular access type and reasons for use of a vascular catheter.

OUTCOMES & MEASUREMENTS

Demographic/clinical characteristics, including the reason provided for use of a vascular catheter, and the association of type of vascular access and (1) patient size and (2) time to kidney transplantation.

RESULTS

Of 1,284 prevalent pediatric CPM patients examined, 529 (41%) had an AVF/AVG and 755 (59%) had a vascular catheter. Of 755 children with a catheter, "small body size" was a commonly listed reason (N = 142); 49% of these children weighed 20 kg or more. Of 53 patients with catheters described as having an "AVF/AVG maturing" and present in the consecutive ESRD CPM project year, 64% had a functioning AVF/AVG the following year. For those with "transplantation scheduled" listed as a reason for a vascular catheter (N = 83), 69% underwent transplantation within 1 year, and median time to transplantation was 115 days. Of all children with vascular catheters (N = 755), 32.2% underwent transplantation within 1 year, and median time to transplantation was 264 days compared with 21.7% and 347 days for those with AVFs/AVGs, respectively (N = 529). Of the 445 incident children in this cohort, 89% had a vascular catheter at dialysis therapy initiation.

LIMITATIONS

Because of study design, only associations can be described.

CONCLUSIONS

Vascular catheter use in children on HD therapy is high. This is partially explained by expeditious transplantation and technical barriers to AVF/AVG placement in small children; however, only one-third of patients with a vascular catheter underwent transplantation within 1 year. Interventions to decrease vascular catheter use in this population may be necessary.

Serum albumin level and risk for mortality and hospitalization in adolescents on hemodialysis

BACKGROUND AND OBJECTIVES

National Kidney Foundation Dialysis Outcomes Quality Initiative practice guidelines recommend serum albumin > or = 4.0 g/dl for adults who are on hemodialysis. There is no established pediatric target for albumin and little evidence to support use of adult guidelines. This study examined the association between albumin and risk for death and hospitalization in adolescents who are on hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study linked data on patients aged 12 to 18 yr in 1999 and 2000 from the Centers for Medicare and Medicaid Services' End Stage Renal Disease Clinical Performance Measures Project with 4-yr hospitalization and mortality records in the United States Renal Data System. Albumin was categorized as < 3.5/3.2, > or = 3.5/3.2 and < 4.0/3.7, and > or = 4.0/3.7 g/dl.

RESULTS

Of 675 adolescents, 557 were hospitalized and 50 died. Albumin > or = 4.0/3.7 g/dl was associated with male gender, Hispanic ethnicity, and higher hemoglobin level. Those with albumin > or = 4.0/3.7 g/dl had fewer deaths per 100 patient-years and fewer hospitalizations per time at risk. In multivariate analysis, patients with albumin > or = 4.0/3.7 g/dl had 57% decreased risk for death. Poisson regression showed progressive decrease in hospitalization risk as albumin level increased; however, confidence intervals were similar between albumin > or = 4.0/3.7 g/dl and albumin > or = 3.5/3.2 and < 4.0/3.7 g/dl.

CONCLUSIONS

This study demonstrates decreased mortality and hospitalization risk with albumin > or = 3.5/3.2 g/dl and suggests that adolescent hemodialysis patients who are able to achieve serum albumin > or = 4.0/3.7 g/dl may have the lowest mortality risk.