AB0835 THE IMPACT OF ADALIMUMAB VS PLACEBO ON PATIENT-REPORTED OUTCOMES AND UTILITY MEASURES AMONG PATIENTS WITH MODERATELY TO SEVERELY ACTIVE PSORIATIC ARTHRITIS

Background:

Physical function and health-related quality of life(HRQoL) are negatively impacted in patients(pts) with PsA. Treatment with conventional and biological (b) DMARDs improved patient-reported outcomes(PROs).

Objectives:

To assess impact of adalimumab(ADA) vs placebo(PBO) on PROs following 12-week (wk) treatment.

Methods:

Pts(n=315) with moderately to severely active PsA and bDMARD naive were randomized to ADA 40mg or PBO every other wk. We assessed PROs at baseline(BL) and wk 12 using the 36-item Short-Form(SF-36) Health Survey physical(PCS) and mental component summary(MCS) scores, 8 domain scores ranging from 0(worst) to 100(best), and SF-6D utility measure derived from all 8 SF-36 domains with scores ranging from 0.296(worst) to 1.00(full health) and minimally important difference(MID) of 0.041. Patient Global Assessment of disease activity(PtGA) and pain(both utilizing 100 mm visual analog scale[VAS]) and HAQ disability index(DI) were assessed. Mean changes from BL, percentages of pts with improvements ≥minimum clinically important differences(MCID), and scores ≥US age-and gender-matched normative values(A/G norms) were analyzed, based on as observed data.Pvalues were assessed by analysis of variance model for continuous variables andCochran–Mantel–Haenszeltest for binary outcomes, adjusting by baseline MTX use and extent of psoriasis. Numbers needed to treat(NNTs) are reported using proportions of pts reporting improvements ≥MCID in SF-36, PtGA, pain, and HAQ-DI.

Results:

BL PRO scores were similar between ADA(n=151) and PBO(n=162;Table 1). Improvements from BL at wk 12 with ADA vs PBO were significant in PtGA, pain, HAQ-DI, and SF-36 PCS(change: 9.3 vs 1.4;P<0.001) but not in SF-36 MCS(1.6 vs 1.2;Table 1). Six of 8 SF-36 domains significantly improved from BL to wk 12 with ADA vs PBO(allP≤0.05;Table 1andFigure 1). SF-6D improvements exceeded MID with ADA(change: 0.071) vs PBO(0.018). Proportions of pts reporting improvements ≥MCID at wk 12 were significantly greater with ADA vs PBO in all PROs, except SF-36 role emotional and mental health domains, with corresponding NNTs ≤6.4(Figure 2). Proportions of pts who reported scores ≥A/G norms in HAQ-DI, SF-36 PCS, and 6 of 8 SF-36 domains were significantly greater with ADA vs PBO(Figure 2).

Table 1.

Mean Disease Characteristics and SF-36 Domain Scores by Treatment Group at Baseline and Wk 12 Compared With Age-and Gender-Matched Normative Values

ADA 40 mg eowPBOA/G normsBaselineWeek 12[change from baseline to week 12]BaselineWeek 12[change from baseline to week 12]SF-36 PCS33.242.5[9.3**]33.334.7[1.4]≥50SF-36 MCS48.149.8[1.6]46.648.4[1.2]≥50SF-6D0.6530.724[0.071]0.6410.659[0.018]—PtGA47.125.9[–21.7**]48.147.5[0.2]—Pt pain51.126.8[–24.1**]48.849.1[1.3]—HAQ-DI1.00.6[–0.4**]1.00.9[–0.1]≤0.25Baseline(vs A/G norms)Week 12(vs A/G norms)Baseline(vs A/G norms)Week 12(vs A/G norms)Physical Functioning50.8(−31.5)65.9***(−16.4)48.2(−34.1)52.0(−30.3)82.3Role Physical37.1(−45.9)65.9***(−17.1)32.6(−50.4)40.6(−42.4)83.0Bodily Pain41.3(−31.6)61.0***(−11.9)40.2(−32.7)43.7(−29.2)72.9General Health49.5(−20.8)62.1***(−8.2)52.1(−18.2)53.0(−17.3)70.3Vitality41.4(−17.8)55.1***(−4.1)41.6(−17.6)45.0(−14.2)59.2Social Functioning66.3(−19.0)77.8†(−7.5)61.7(−23.6)66.7(−18.6)85.3Role Emotional65.1(−23.4)70.4(−18.1)59.1(−29.4)66.0(−22.5)88.5Mental Health67.6(−8.5)72.9(−3.2)64.9(−11.2)67.3(−8.8)76.1

ADA, adalimumab; A/G norm, age-and gender-matched normative value; eow, every other week; DI, disability index; MCS, mental component summary; MID, minimally important difference; PBO, placebo; PCS, physical component summary; PtGA, Patient Global Assessment of disease activity; SF-36, 36-item Short-Form Health Survey; SF-6D, Short-Form 6D.

SF-6D MID=0.041.

Statistical analysis ADA vs PBO:†P<0.05; *P<0.01; **P<0.001; ***P<0.0001.

Conclusion:

Statistically significant and clinically meaningful improvements and scores ≥A/G norms(higher definition of response) at week 12 were reported with ADA vs PBO in pts with moderately to severely active PsA.

Disclosure of Interests:

Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Pankaj Patel Shareholder of: AbbVie, Employee of: AbbVie, Naijun Chen Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Elizabeth Lesser Shareholder of: AbbVie Inc, Employee of: AbbVie Inc

THU0546 HEALTHCARE COSTS OF NOT ACHIEVING REMISSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Guidelines recommend sustained remission as a treatment goal for patients with rheumatoid arthritis (RA). However, only one-third of patients are known to achieve this goal with current treatments. A few studies have evaluated the impact of remission in a real-world setting, but evidence is limited to the elderly population.

Objectives:

To understand the impact of remission on healthcare costs by comparing overall and RA-related direct healthcare costs and resource use in patients with RA who maintain vs those who do not maintain remission using a real-world database.

Methods:

Data for this retrospective cohort study were derived from Optum electronic health records linked to claims from commercial and Medicare Advantage health plans in the United States. Patients with ≥2 diagnoses for RA, ≥1 Disease Activity Score 28 (DAS28-CRP/ESR) or Routine Assessment of Patient Index Data 3 (RAPID3) measurement, and continuous medical and pharmacy coverage 6 months before and 1 year after the index date were included. Two cohorts were created: remission and non-remission. Remission was defined as DAS28 <2.6 or RAPID3 ≤3.0. In the remission cohort, the index date was defined as the first date remission was achieved. In the non-remission cohort, the index date was defined as the first date of DAS28 or RAPID3 measurement. Outcomes were all-cause and RA-related total, medical, and prescription costs; healthcare resource use (number of inpatient, emergency department [ED], outpatient, and other visits); and number of prescriptions within 1 year of index date. A weighted generalized linear model and binomial regression were used to estimate adjusted annual direct costs and healthcare resource use, respectively. Confounding between cohorts due to age, sex, race and comorbidities using the Elixhauser index was controlled for in the models.

Results:

A total of 335 patients with RA (remission cohort: 125; non-remission cohort: 210) met the study inclusion criteria. Annual all-cause total direct costs in the remission cohort were significantly less than in the non-remission cohort ($30,427 vs $38,645, respectively; cost ratio (CR)=0.79; 95% CI: 0.63, 0.99). All-cause medical costs were significantly lower in the remission cohort than in the non-remission cohort (Figure 1); furthermore, among all-cause medical costs, outpatient visit costs were significantly lower in the remission than in the non-remission cohort. All-cause resource use (mean number of visits) was less in the remission vs non-remission cohort: inpatient (0.23 vs 0.63; visit ratio (VR)=0.36; 95% CI: 0.19, 0.70), ED (0.36 vs 0.77; VR=0.47; 95% CI: 0.30, 0.74), and outpatient visits (20.7 vs 28.5; VR=0.73; 95% CI: 0.62, 0.86). Annual RA-related total direct costs were similar in both cohorts (Figure 2); however, RA-related medical costs were numerically lower in the remission vs non-remission cohort ($8,594 vs $10,002, respectively; CR=0.86; 95% CI: 0.59, 1.25). RA-related resource use (mean number of visits) was less in the remission vs non-remission cohort: inpatient (0.15 vs 0.22; VR=0.67; 95% CI: 0.35, 1.30), ED (0.04 vs 0.13; VR=0.31; 95% CI: 0.10, 0.95), and outpatient visits (5.4 vs 7.4; VR=0.72; 95% CI: 0.58, 0.91).

Conclusion:

Significant economic burden was associated with patients who did not maintain remission compared with those who maintained remission. Although outpatient visits were the driver of medical costs in both groups studied in this analysis, the contribution of outpatient visits was greater among those who did not maintain remission.

Acknowledgments:

Financial support for the study was provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. All authors contributed to the development of the publication and maintained control over the final content. Medical writing services were provided by Joann Hettasch of JK Associates Inc., a member of the Fishawack Group of Companies, and funded by AbbVie.

Disclosure of Interests:

Martin Bergman Shareholder of: Johnson & Johnson – stockholder, Consultant of: AbbVie, BMS, Celgene Corporation, Genentech, Janssen, Merck, Novartis, Pfizer, Sanofi – consultant, Speakers bureau: AbbVie, Celgene Corporation, Novartis, Pfizer, Sanofi – speakers bureau, Lili Zhou Shareholder of: AbbVie, Employee of: AbbVie, Pankaj Patel Shareholder of: AbbVie, Employee of: AbbVie, Ruta Sawant Shareholder of: AbbVie, Employee of: AbbVie, Jerry Clewell Shareholder of: AbbVie, Employee of: AbbVie, Namita Tundia Shareholder of: AbbVie, Employee of: AbbVie

Azimuthal Drive Asymmetry in Inertial Confinement Fusion Implosions on the National Ignition Facility

Data from nuclear diagnostics present correlated signatures of azimuthal implosion asymmetry in recent indirect-drive inertial confinement fusion (ICF) implosion campaigns performed at the National Ignition Facility (NIF). The mean hot-spot velocity, inferred from the Doppler shift of 14 MeV neutrons produced by deuterium-tritium (DT) fusion, is systematically directed toward one azimuthal half of the NIF target chamber, centered on ϕ≈70°. Areal density (ρR) asymmetry of the converged DT fuel, inferred from nuclear activation diagnostics, presents a minimum ρR in the same direction as the hot-spot velocity and with ΔρR amplitude correlated with velocity magnitude. These two correlated observations, which are seen in all recent campaigns with cryogenic layers of DT fuel, are a known signature of asymmetry in the fuel convergence, implying a systematic azimuthal drive asymmetry across a wide range of shot and target configurations. The direction of the implied radiation asymmetry is observed to cluster toward the hohlraum diagnostic windows. This low-mode asymmetry degrades hot-spot conditions at peak convergence and limits implosion performance and yield.

The Elements of British Technological Competitiveness

In this election year of 1987 the state of Britain's technology has remained high on the political agenda. Following the critical report from the House of Lords on civil research and development (1986), the government recently announced changes in its machinery and priorities and expressed concern about British industry's (lack of) funding of R and D compared to the main sources of foreign competition (see HM Government, 1987).

Comparison of perinatal outcomes between spontaneous vs. commissioned cycles in gestational carriers for single and same-sex male intended parents

PURPOSE

To determine whether gestational carrier (GC) in vitro fertilization (IVF) cycles (commissioned cycles) for same-sex or single male intended parents have an increased incidence of adverse perinatal outcomes compared with spontaneous cycles in the same GCs.

DESIGN

GC singleton pregnancies were identified from a database of 895 commissioned cycles from a large fertility center. Of these, 78 commissioned cycles met inclusion and exclusion criteria and were compared with 71 spontaneous cycles by the same GCs. The primary outcome was the composite score for adverse perinatal outcomes. Secondary outcomes included mode of delivery, birthweight, and gestational age. Chi-square test of association and Mann-Whitney U tests were used to compare categorical and continuous variables between the cohorts, respectively. Logistic and linear regressions controlling for GC age were constructed to determine the influence of GC cycle type on adverse perinatal outcomes.

RESULTS

Commissioned cycles were significantly associated with adverse perinatal outcomes (25.6% vs. 9.9%; p = 0.02) and lower average gestational age (38.7 ± 1.5 vs. 39.4 ± 0.9; p < 0.001) compared with spontaneous cycles. Commissioned cycle increased the likelihood of adverse perinatal outcomes (OR 3.3; p = 0.03) and was a significant independent predictor of a lower average gestational age (β = 0.897; p < 0.001). There were no significant differences in the incidence of vaginal deliveries or cesarean sections between commissioned and spontaneous cycles.

CONCLUSIONS

Commissioned cycles confer a greater incidence of composite perinatal complications and were independently associated with a lower average gestational age when compared with spontaneous pregnancies carried by the same GC despite a confirmed healthy uterine environment, sperm samples, and donor oocytes.

Determination of Retinyl Palmitate (Vitamin A) in Fortified Fluid Milk by Liquid Chromatography: Collaborative Study

A liquid chromatographic (LC) method was developed for fast and simple measurement of retinyl palmitate (vitamin A) in fortified milk. Retinyl acetate internal standard was added to a test portion of milk followed by extraction into hexane. The hexane extract was analyzed by LC using a normal-phase silica gel column equilibrated with mobile phase (conditioned hexane–isopropanol, 99.85 + 0.15, v/v) about 1 h before injections. The retinyl palmitate concentration was calculated by using a relative response factor determined with calibration standards. In the collaborative study, 11 laboratories analyzed 13 pairs of fluid milk materials in blind duplicate. Twelve of the materials were composed of skim milk (&lt;0.5% fat), 1% fat milk, 2% fat milk, and 1% fat chocolate milk. Each material was fortified at 3 concentrations of retinyl palmitate of approximately 581 μg/L (1000 IU/qt), 1163 μg/L (2000 IU/qt), and 2236 μg/L (4000 IU/qt). The 13th material, unfortified skim milk, served as a matrix blank. Repeatability standard deviations (RSDr) without outliers ranged from 1.5 to 5.7% and reproducibility standard deviations (RSDR) without outliers ranged from 5.0 to 22.7%. cis-Isomers co-eluted with the predominant trans-retinyl palmitate isomer and were included in the results reported by all the collaborative laboratories. Endogenous long-chain esters from milk fat were also measured with the retinyl palmitate additive. The Study Director recommends that this method for determination of retinyl palmitate in fluid milk by LC be adopted First Action.

Validation of an Immunoassay for Detection and Quantitation of a Genetically Modified Soybean in Food and Food Fractions Using Reference Materials: Interlaboratory Study

An immunoassay for detection of a specific genetically modified soybean (Roundup-Ready®) was validated on dried soybean powder in an interlaboratory study. Different percentages of genetically modified soybeans in nonmodified soybean matrix were evaluated in a blind study. Thirty-eight laboratories from 13 countries participated. The immunoassay was evaluated for 2 endpoints: (1) To give a semiquantitative result, i.e., determination of a given sample above or below a given threshold, or (2) to compute a quantitative result, i.e., percentage of genetically modified soybeans in the sample. Semiquantitative results showed that a given sample which contained &lt;2% genetically modified soybeans was identified as below 2% with a 99% confidence level. Quantitative use of the assay resulted in a repeatability (r) and reproducibility (R) that were computed to be RSDr = 7% and RSDR = 10%, respectively, for a sample containing 2% genetically modified soybeans. Application of this method depends on availability of appropriate reference materials for a specific food matrix. Only matrix-matched reference materials can be used for analysis of food or food fractions.

Perceptions of e-professionalism among dental students: a UK dental school study

Introduction

The social media activity of some healthcare students has created doubt about their ability to uphold and defend the ethical principles of healthcare in their online behaviours. A lot of research has been conducted on the online behaviours of medical and allied health professional students, however, less has been undertaken on dental students.

Aims

The aim was to determine whether students were aware of the guidelines set by the General Dental Council (GDC) regarding social media and whether they believed they were being professional in their online activities.

Methods and materials

Eighty-eight dental students (46 from year 2; 42 from year 4) at one UK dental school completed a questionnaire study examining their attitude towards and perceptions of e-professionalism.

Results

The results show that most students were heavy users of social media with an awareness of social media guidelines set out by the GDC. However, student responses to various e-professionalism scenarios reveals disagreement on whether posts referring to alcohol and work colleagues were deemed unprofessional.

Conclusion

Student perceptions of and attitudes towards e-professionalism is complicated and contradictory. More research will need to be undertaken to explore how we can inculcate e-professional values and behaviours in dental professionalism teaching.

1424The diagnosis of non-adherence in hypertension using a urine biochemical screen is unaffected by drug pharmacokinetics

Introduction

Suboptimal drug adherence in hypertension is pandemic and traditional diagnostic tools to detect non-adherence have lacked accuracy and robustness. The inability to identify non-adherence has therefore driven the development of biochemical drug screening by liquid chromatography tandem mass spectrometry (LC- MS/MS) in urine and blood, which are the most accurate metrics presently available. Urinary antihypertensive testing is evidenced to improve non-adherence rates, significantly decrease blood pressure after physician intervention, and be cost effective. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2018 guidelines have recommended the use of biochemical testing for non-adherence diagnosis. However, it has been argued that the variable pharmacokinetic parameters of the medication (such as their half-lives and clearance rates) may affect the detection of medications in urine and hence the determination of adherence. We hypothesized that pharmacokinetic parameters do not affect the detection of antihypertensive medications in urine.

Aim

This study compared the pharmacokinetic parameters of the most commonly prescribed antihypertensive medications against their detection in urine by LC-MS/MS.

Methods

Results of urinary drug screens from 463 hypertensive patients (total prescribed medications N=1709) were collated. An adherence score termed as the C score (number of detected vs. prescribed medication) was generated for each of the 27 common antihypertensive medications. Pharmacokinetic parameters such as bioavailability, plasma concentration, volume of distribution, half-life, plasma clearance and urinary excretion values for each drug were obtained from published literature. Partial linear correlation was conducted between the C score of all the medications and each pharmacokinetic parameter studied.

Results

40% of patients were non-adherent. The average number of prescribed medications was high (N=3.7, SD: 1.5), and the average number of drugs detected was lower (N=2.5, SD: 1.6). Amlodipine was the most prescribed (N=224), and clonidine was the least (N=10). The half-lives ranged from 0.87 to 39 hours for bumetanide and amlodipine respectively. The urinary excretion percentage varied from <1% for nifedipine, and 94% for benfroflumethiazide. No significant correlation was found between any drug C score and their respective pharmacokinetic variables such as the medication half-lives (figure1).

Half-life versus adherence score

Conclusion

This study reports no significant correlation between drug pharmacokinetics and adherence. To the best of our knowledge this is the first study of its kind. Urinary biochemical testing by LC-MS/MS for non-adherence remains a valid tool for diagnosis although further detailed pharmacokinetic studies are needed to confirm this finding.

Acknowledgement/Funding

None

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.