Comparison of Clinical Decision Support Tools to Improve Pediatric Lipid Screening

OBJECTIVE

To test whether different clinical decision support tools increase clinician orders and patient completions relative to standard practice and each other.

STUDY DESIGN

A pragmatic, patient-randomized clinical trial in the electronic health record was conducted between October 2019 and April 2020 at Geisinger Health System in Pennsylvania, with 4 arms: care gap-a passive listing recommending screening; alert-a panel promoting and enabling lipid screen orders; both; and a standard practice-no guideline-based notification-control arm. Data were analyzed for 13 346 9- to 11-year-old patients seen within Geisinger primary care, cardiology, urgent care, or nutrition clinics, or who had an endocrinology visit. Principal outcomes were lipid screening orders by clinicians and completions by patients within 1 week of orders.

RESULTS

Active (care gap and/or alert) vs control arm patients were significantly more likely (P < .05) to have lipid screening tests ordered and completed, with ORs ranging from 1.67 (95% CI 1.28-2.19) to 5.73 (95% CI 4.46-7.36) for orders and 1.54 (95% CI 1.04-2.27) to 2.90 (95% CI 2.02-4.15) for completions. Alerts, with or without care gaps listed, outperformed care gaps alone on orders, with odds ratios ranging from 2.92 (95% CI 2.32-3.66) to 3.43 (95% CI 2.73-4.29).

CONCLUSIONS

Electronic alerts can increase lipid screening orders and completions, suggesting clinical decision support can improve guideline-concordant screening. The study also highlights electronic record-based patient randomization as a way to determine relative effectiveness of support tools.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04118348.

A Randomized Trial of Behavioral Nudges Delivered Through Text Messages to Increase Influenza Vaccination Among Patients With an Upcoming Primary Care Visit

PURPOSE

To evaluate if nudges delivered by text message prior to an upcoming primary care visit can increase influenza vaccination rates.

DESIGN

Randomized, controlled trial.

SETTING

Two health systems in the Northeastern US between September 2020 and March 2021.

SUBJECTS

74,811 adults.

INTERVENTIONS

Patients in the 19 intervention arms received 1-2 text messages in the 3 days preceding their appointment that varied in their format, interactivity, and content.

MEASURES

Influenza vaccination.

ANALYSIS

Intention-to-treat.

RESULTS

Participants had a mean (SD) age of 50.7 (16.2) years; 55.8% (41,771) were female, 70.6% (52,826) were White, and 19.0% (14,222) were Black. Among the interventions, 5 of 19 (26.3%) had a significantly greater vaccination rate than control. On average, the 19 interventions increased vaccination relative to control by 1.8 percentage points or 6.1% (P = .005). The top performing text message described the vaccine to the patient as "reserved for you" and led to a 3.1 percentage point increase (95% CI, 1.3 to 4.9; P < .001) in vaccination relative to control. Three of the top five performing messages described the vaccine as "reserved for you." None of the interventions performed worse than control.

CONCLUSIONS

Text messages encouraging vaccination and delivered prior to an upcoming appointment significantly increased influenza vaccination rates and could be a scalable approach to increase vaccination more broadly.

Prediction of Influenza Complications: Development and Validation of a Machine Learning Prediction Model to Improve and Expand the Identification of Vaccine-Hesitant Patients at Risk of Severe Influenza Complications

Influenza vaccinations are recommended for high-risk individuals, but few population-based strategies exist to identify individual risks. Patient-level data from unvaccinated individuals, stratified into retrospective cases (n = 111,022) and controls (n = 2,207,714), informed a machine learning model designed to create an influenza risk score; the model was called the Geisinger Flu-Complications Flag (GFlu-CxFlag). The flag was created and validated on a cohort of 604,389 unique individuals. Risk scores were generated for influenza cases; the complication rate for individuals without influenza was estimated to adjust for unrelated complications. Shapley values were used to examine the model’s correctness and demonstrate its dependence on different features. Bias was assessed for race and sex. Inverse propensity weighting was used in the derivation stage to correct for biases. The GFlu-CxFlag model was compared to the pre-existing Medial EarlySign Flu Algomarker and existing risk guidelines that describe high-risk patients who would benefit from influenza vaccination. The GFlu-CxFlag outperformed other traditional risk-based models; the area under curve (AUC) was 0.786 [0.783−0.789], compared with 0.694 [0.690−0.698] (p-value < 0.00001). The presence of acute and chronic respiratory diseases, age, and previous emergency department visits contributed most to the GFlu-CxFlag model’s prediction. When higher numerical scores were assigned to more severe complications, the GFlu-CxFlag AUC increased to 0.828 [0.823−0.833], with excellent discrimination in the final model used to perform the risk stratification of the population. The GFlu-CxFlag can better identify high-risk individuals than existing models based on vaccination guidelines, thus creating a population-based risk stratification for individual risk assessment and deployment in vaccine hesitancy reduction programs in our health system.

The Association of Oral Stimulant Medication Adherence with Work Productivity among Adults with ADHD

OBJECTIVE

Examine associations between oral psychostimulant pharmacotherapy adherence, work productivity, and related indirect costs among US adults with ADHD.

METHODS

Medication adherence (Medication Adherence Reasons Scale [MAR-Scale]), work productivity and activity impairment (Work Productivity and Activity Impairment-General Health questionnaire), and ADHD symptom level (Adult ADHD Self-Report Scale version 1.1 Symptom Checklist) were assessed in this noninterventional online survey of adults who self-reported having an ADHD diagnosis and were currently receiving oral psychostimulant treatment for ≥3 months.

RESULTS

Of 602 respondents, 395 had low/medium adherence (LMA: MAR-Scale total score ≥1) and 207 had high adherence (HA: MAR-Scale total score 0). After adjusting for covariates, the LMA group had significantly greater levels of absenteeism, absenteeism-related indirect costs, and total indirect costs (all p < .01) than the HA group.

CONCLUSION

In adults with ADHD using oral psychostimulants, lower medication adherence was associated with greater absenteeism and indirect costs.

Early COVID-19 therapy with azithromycin plus nitazoxanide, ivermectin or hydroxychloroquine in outpatient settings significantly improved COVID-19 outcomes compared to known outcomes in untreated patients

In a prospective observational study (pre-AndroCoV Trial), the use of nitazoxanide, ivermectin and hydroxychloroquine demonstrated unexpected improvements in COVID-19 outcomes when compared to untreated patients. The apparent yet likely positive results raised ethical concerns on the employment of further full placebo controlled studies in early-stage COVID-19. The present analysis aimed to elucidate, through a comparative analysis with two control groups, whether full placebo-control randomized clinical trials (RCTs) on early-stage COVID-19 are still ethically acceptable. The Active group (AG) consisted of patients enrolled in the Pre-AndroCoV-Trial (n = 585). Control Group 1 (CG1) consisted of a retrospectively obtained group of untreated patients of the same population (n = 137), and Control Group 2 (CG2) resulted from a precise prediction of clinical outcomes based on a thorough and structured review of indexed articles and official statements. Patients were matched for sex, age, comorbidities and disease severity at baseline. Compared to CG1 and CG2, AG showed reduction of 31.5-36.5% in viral shedding (p < 0.0001), 70-85% in disease duration (p < 0.0001), and 100% in respiratory complications, hospitalization, mechanical ventilation, deaths and post-COVID manifestations (p < 0.0001 for all). For every 1000 confirmed cases for COVID-19, at least 70 hospitalizations, 50 mechanical ventilations and five deaths were prevented. Benefits from the combination of early COVID-19 detection and early pharmacological approaches were consistent and overwhelming when compared to untreated groups, which, together with the well-established safety profile of the drug combinations tested in the Pre-AndroCoV Trial, precluded our study from continuing employing full placebo in early COVID-19.

Effect of Targeted Behavioral Science Messages on COVID-19 Vaccination Registration Among Employees of a Large Health System: A Randomized Trial

This randomized trial evaluates whether individually addressed emails designed with behaviorally informed features increase COVID-19 vaccination rates.

Informing patients that they are at high risk for serious complications of viral infection increases vaccination rates

For many vaccine-preventable diseases like influenza, vaccination rates are lower than optimal to achieve community protection. Those at high risk for infection and serious complications are especially advised to be vaccinated to protect themselves. Using influenza as a model, we studied one method of increasing vaccine uptake: informing high-risk patients, identified by a machine learning model, about their risk status. Patients (N=39,717) were evenly randomized to (1) a control condition (exposure only to standard direct mail or patient portal vaccine promotion efforts) or to be told via direct mail, patient portal, and/or SMS that they were (2) at high risk for influenza and its complications if not vaccinated; (3) at high risk according to a review of their medical records; or (4) at high risk according to a computer algorithm analysis of their medical records. Patients in the three treatment conditions were 5.7% more likely to get vaccinated during the 112 days post-intervention (p < .001), and did so 1.4 days earlier (p < .001), on average, than those in the control group. There were no significant differences among risk messages, suggesting that patients are neither especially averse to nor uniquely appreciative of learning their records had been reviewed or that computer algorithms were involved. Similar approaches should be considered for COVID-19 vaccination campaigns.

Disparities in healthcare providers' interpretations and implementations of ACIP's meningococcal vaccine recommendations

Invasive meningococcal disease (IMD) caused by the bacteria Neisseria meningitidis is rare but potentially fatal. For healthy adolescents, the US Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination with MenACWY and recommends MenB vaccination under shared clinical decision-making (previously "Category B"). The recommendation for MenB vaccination was the first category B recommendation in adolescents, and it is unclear how healthcare providers (HCPs) implement these guidelines. This 2017 web-based survey of US HCPs explored characteristics associated with prescribing or receiving MenB and MenACWY vaccines, HCP knowledge of vaccine recommendations, and real-world practice patterns. Of 529 respondents, 436 prescribed MenB vaccines to their eligible adolescent/young adult patients and 93 prescribed MenACWY vaccines only. MenB vaccine prescribers were more likely to be pediatricians compared with MenACWY vaccine only prescribers, and patients who received MenB vaccines were more likely to be non-Hispanic whites living in shared spaces (eg, college dormitories) than those not receiving the vaccine. Seventy-seven percent of HCPs indicated that they prescribe MenACWY vaccines consistently with ACIP recommendations (to all members of an age group), whereas only 7% indicated that they prescribe MenB vaccines consistently with ACIP recommendations (individual clinical decision making). Patient-related factors, disease-related factors, and guidelines all influenced HCP decisions to prescribe meningococcal vaccines. Providing HCPs with clear guidance on how to initiate discussion of MenB vaccines with patients and their caregivers may aid in fully protecting US adolescents against meningococcal disease caused by 5 of the disease-causing serogroups.

Erosive pustular dermatosis of the scalp: a multicentre study

BACKGROUND

Erosive pustular dermatosis of the scalp (EPDS) is characterized by crusted erosions or superficial ulcerations that lead to scarring alopecia.

OBJECTIVES AND METHODS

We performed a multicentre retrospective clinical study including 56 patients (29 females and 27 males, mean age 62.7) with a confirmed EPDS in order to describe epidemiology, clinical findings and therapeutic choices of this disease.

RESULTS

Mechanical/chemical trauma was reported in 28.6%, a previous infection in 10.7%, a previous cryotherapy in 5.4% androgenetic alopecia in 48.2% and severe actinic damage in 25%. Trichoscopy showed absence of follicular ostia, tufted and broken hair, crusts, serous exudate, dilated vessels, pustules and hyperkeratosis. Histopathology revealed three different features, depending on the disease duration. The most prescribed therapy was topical steroids (62.5%), followed by the combination of topical steroids and topical tacrolimus (8.9%), systemic steroids (7.1%) and topical tacrolimus (5.4%). A reduction of inflammatory signs was observed in 28 patients (50%) treated with topical steroids and in all three patients treated with topical tacrolimus.

CONCLUSION

The relatively high number of patients collected allowed us to identify a better diagnostic approach, using trichoscopy and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

The association of erectile dysfunction with productivity and absenteeism in eight countries globally

AIM

To evaluate the association of erectile dysfunction (ED) with work productivity loss, activity impairment and health-related quality of life (HRQoL) across Brazil, China, France, Germany, Italy, Spain, the UK and the US.

METHODS

This cross-sectional observational study used data from adult men (40-70 years old; N = 52 697) from the 2015 and 2016 National Health and Wellness Surveys. ED assessment was based on self-reported difficulty in achieving or maintaining an erection in the past 6 months. Impairment to work and non-work activities and HRQoL were assessed for each country and compared against the US. Multivariable models tested interactions between ED status and country for each outcome.

RESULTS

Overall ED prevalence was reported as 49.7%, with Italy reporting the highest rate (54.7%). Men with ED reported significantly higher absenteeism (7.1% vs 3.2%), presenteeism (22.5% vs 10.1%), overall work productivity impairment (24.8% vs 11.2%), activity impairment (28.6% vs 14.5%) and significantly lower Mental Component Summary scores (MCS; 46.7 vs 51.2), Physical Component Summary scores (PCS; 48.3 vs 53.0), and health state utilities (SF-6D: 0.693 vs 0.778; all, P < 0.001) than men with no ED. After adjusting for covariates, compared with the US, the association of ED status with overall work productivity impairment was greatest in the UK (26% higher; P < 0.05), and with MCS, PCS and SF-6D scores was greatest in China (-2.67, -1.58, and -0.043 points, respectively; all, P < 0.001). Greater ED severity was significantly associated with higher impairment to work and non-work activities and lower HRQoL, with China reporting the highest burden, compared with the US (most P < 0.05).

CONCLUSION

ED poses a significant burden with respect to work productivity and HRQoL, with greater severity associated with worse outcomes. Better management and earlier detection may help reduce this burden, especially in countries reporting a strong association between ED and poor economic and health outcomes.

National Health and Wellness Survey exploratory cluster analysis of males 40-70 years old focused on erectile dysfunction and associated risk factors across the USA, Italy, Brazil and China

OBJECTIVES

Prior studies of erectile dysfunction (ED) tend to narrowly focus on relationships with specific comorbidities, rather than evaluating a more comprehensive array of risk factors and assessing naturalistic patterns among them. This study identifies natural clusters of male characteristics from a general population sample per country, quantifies ED dynamics in these profiles and compares profiles across the US, Italy, Brazil and China samples.

METHODS

National Health and Wellness Survey 2015 and 2016 patient-reported data on men aged 40-70 years (USA n = 15,652; Italy n = 2,521; Brazil n = 2,822; China n = 5,553) were analysed. Hierarchical agglomerative clustering identified clusters where predictors included demographics, health characteristics/behaviours, ED risk factors and provider visits in the past 6 months. Multinomial logistic regression assessed the independent utility of variables in predicting cluster membership, compared with the healthiest control cluster per country.

RESULTS

Different natural clusters were found across countries, with four clusters for the USA, Italy and China and three clusters for Brazil. Age, income, employment, health behaviours and ED risk factors predicted different cluster membership across countries. In the USA, Italy and Brazil, younger clusters were predicted by ED, unhealthy behaviours and ED risk factors. Unique cluster profiles were identified in China, with ED and ED risk factors (aside from hypertension) not predicting cluster membership, while socio-demographics and health behaviours were strongly predictive.

CONCLUSIONS

Natural cluster profiles revealed notable ED rates among adult males of age 40-70 in four different countries. Clusters were mainly predicted by unhealthy behaviours, ED risk factors and ED, regardless of level or presence of positive health characteristics and behaviours. This analysis identified meaningful subgroups of men with heightened ED risk factors, which can help healthcare providers to better recognise specific populations with the greatest need for intervention.

Identification of the sulfotransferase iso-enzyme primarily responsible for the bio-activation of topical minoxidil

Pattern hair loss (i.e., androgenetic alopecia) is a common condition afflicting approximately fifty percent of men and women by the age of fifty. Currently, topical minoxidil is the only US FDA approved drug for the treatment of pattern hair loss in men and women.

An empirical tool for estimating the share of unmet need due to healthcare inefficiencies, suboptimal access, and lack of effective technologies

Background

Although there has been growing attention to the measurement of unmet need, which is the overall epidemiological burden of disease, current measures ignore the burden that could be eliminated from technological advances or more effective use of current technologies.

Methods

We developed a conceptual framework and empirical tool that separates unmet need from met need and subcategorizes the causes of unmet need into suboptimal access to and ineffective use of current technologies and lack of current technologies. Statistical models were used to model the relationship between health-related quality of life (HR-QOL) and treatment utilization using data from the National Health and Wellness Survey (NHWS). Predicted HR-QOL was combined with prevalence data from the Global Burden of Disease Study (GBD) to estimate met need and the causes of unmet need due to morbidity in the US and EU5 for five diseases: rheumatoid arthritis, breast cancer, Parkinson’s disease, hepatitis C, and chronic obstructive pulmonary disease (COPD).

Results

HR-QOL was positively correlated with adherence to medication and patient-perceived quality and negatively correlated with financial barriers. Met need was substantial across all disease and regions, although significant unmet need remains. While the majority of unmet need was driven by lack of technologies rather than ineffective use of current technologies, there was considerable variation across diseases and regions. Overall unmet need was largest for COPD, which had the highest prevalence of all diseases in this study.

Conclusion

We developed a methodology that can inform decisions about which diseases to invest in and whether those investments should focus on improving access to currently available technologies or inventing new technologies.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3914-7) contains supplementary material, which is available to authorized users.

Using the Medication Adherence Reasons Scale (MAR-Scale) to identify the reasons for non-adherence across multiple disease conditions

Purpose: With more than 50% of the individuals on chronic conditions not taking medicines as prescribed, it is essential for health care providers to understand the reasons, so that adherence-related conversations can be initiated and focused appropriately. Measuring medication non-adherence is complex, because patients are often on multiple medications and take them via various modes of administration such as orally, by injection, or topically, and at various frequencies such as daily or weekly. The Medication Adherence Reasons Scale (MAR-Scale) is a twenty-item, self-reported, comprehensive scale developed to measure two aspects of medication non-adherence: the extent or frequency of non-adherence and reasons for non-adherence. The objective of this study was to identify the top reasons, in 17 distinct chronic disease conditions, reported by patients for being non-adherent across various modes and frequencies of the corresponding medications. Internal reliability of the MAR-Scale was also assessed in each condition. Patients and methods: Results were derived from Kantar Health's US 2017 National Health and Wellness Survey (NHWS), a self-administered, annual, Internet-based cross-sectional survey of 75,000 adults (≥18 years). The survey sample was drawn from an Internet panel and was stratified according to age, gender, and ethnicity in order to represent the US adult population based on the US Census Bureau. Respondents to the 2017 NHWS who self-reported taking prescription medication(s) to treat one of the 17 conditions were invited to complete the MAR-Scale in a follow-up online survey, reporting on reasons for non-adherence in the past 7 days (daily medications) or four weeks (weekly), with non-adherence defined as any reported non-adherence in the corresponding timeframe for medicines taken orally, by injection, and topically. Results: MAR-Scale data were obtained from 15,672 respondents in one or more conditions, modes, and frequencies. MAR-Scale reliability ranged from Cronbach's alpha of 0.861 in multiple sclerosis to 0.973 in psoriasis. For daily orals, non-adherence ranged from 25.2% in diabetes to 63.7% in eczema. The most common reasons across conditions were "simply missed it," "side effects," and "concern about long-term effects." Conclusion: The MAR-Scale demonstrates acceptable reliability in multiple chronic disease conditions and across modes and frequencies of administration.

2458. Disparities in Healthcare Providers’ Interpretation and Implementation of ACIP’s Meningococcal Vaccine Recommendations

Background

Serogroup B is the leading cause of invasive meningococcal disease (IMD) in United States. Among 16–23 year olds, particularly for college students, serogroup B (MenB) disease is greater than serogroups C, W, and Y combined. ACIP recommends routine immunization with MenACWY vaccine (Category A) but a non-routine recommendation based on individual clinical decision-making for MenB vaccine (Category B). Contrasting ACIP recommendations may affect how healthcare providers (HCP) prescribe meningococcal vaccines. We aimed to understand HCPs’ decision process and vaccination practice pattern to prescribe meningococcal vaccines in relation to their experience and interpretations of ACIP recommendations.

Methods

A web-based survey was conducted during August–October 2017 among a nationally representative HCP sample. Univariate analyses were conducted.

Results

Of 529 HCP participants, 436 (82.4%) self-identified as prescribers of MenB only or both meningococcal vaccines, and 93 (17.6%) as prescribers of MenACWY vaccine only (Table 1). When HCPs were asked to rank the most impactful factor in their decision process, 45% ranked guideline considerations as the highest in their decisions to prescribe MenACWY to 16 year olds, followed by disease related factors (36%). For MenB vaccine, 40% ranked disease related factors as the highest, followed by guideline considerations (37%); however, contrasting to MenACWY vaccine (45% vs. 24%), there was no difference (37% vs. 38%) regarding how guideline considerations drove the decision to prescribe or not to prescribe MenBvaccine (Table 2). Overall, HCPs interpreted ACIP’s MenACWY recommendation more uniformly than the MenB recommendation (Figure 1) with majority interpreting MenACWY vaccine as for everyone, whereas MenB was split into for everyone or for a sub-group based on risk factors; ~1/4th of MenACWY only prescribers did not know how to interpret the MenB recommendation.

Conclusion

The ACIP MenB vaccine recommendation is inconsistently interpreted across HCPs and might affect their decision process and vaccination practice pattern to prescribe meningococcal vaccines resulting in disparities in access to MenBvaccines.

Disclosures

L. Huang, Pfizer: Employee and Shareholder, Salary and Stocks. A. Goren, Pfizer: Collaborator, Research support. L. Lee, Pfizer: Collaborator, Research support. A. Dempsey, Pfizer, Merck: Scientific Advisor, Consulting fee. A. Srivastava, Pfizer: Employee and Shareholder, Salary.

Treatment satisfaction with pharmaceutical interventions in Japanese adults with osteoarthritis and chronic knee pain: an analysis of a web-based survey

Purpose

Patient satisfaction is an important outcome in successful osteoarthritis (OA) treatment. The aim of this study was to evaluate treatment satisfaction for medication (TSM) in people with knee OA (KOA), identify the factors predictive of treatment satisfaction, and describe the burden of illness.

Patients and methods

This cross-sectional, patient-reported study used an Internet-based survey and analyzed responses of respondents with KOA (N=400) on characteristics including pain sites and levels (including pain ratings using the Numerical Rating Scale and Short-Form McGill Pain Questionnaire), treatment satisfaction (Global, Effectiveness, and Convenience scores) based on the Treatment Satisfaction Questionnaire for Medication (TSQM-9), and quality of life (QoL; based on the Arthritis Impact Measurement Scale 2-Short Form). Respondents with only KOA (n=237) were compared with those having KOA and additional painful sites (KOA+; n=163). Factors predicting TSM were identified using multivariable linear regression analyses.

Results

Respondents with KOA were more likely to report intermittent pain for 3 months or more compared with those with KOA+ (58.6% vs 48.5%, respectively; P=0.044), while those with KOA+ were more likely to report consistent pain for 3 months or more (P=0.022). Respondents with KOA+ also had more difficulty due to their knee pain while sleeping (P=0.022) and resting (P=0.015). Reported TSM did not differ significantly across KOA vs KOA+ groups, with both groups reporting low satisfaction; all domains of QoL were worse for those with KOA+. Knee pain reduction by medication predicted higher satisfaction across domains, while lower pre-medication pain and post-medication pain matching expectations predicted higher TSQM-9 Global and Effectiveness scores.

Conclusion

Medication treatment satisfaction rates were low among Japanese respondents with KOA. Given that lower pain, greater pain reduction post-medication, and meeting pain management expectations were predictive of higher satisfaction, treatment strategies that can better address pain may prove beneficial for overall patient satisfaction.

Low-dose daily aspirin reduces topical minoxidil efficacy in androgenetic alopecia patients

Topical minoxidil is the only US FDA approved OTC drug for the treatment of androgenetic alopecia (AGA). Minoxidil is a pro-drug converted into its active form, minoxidil sulfate, by the sulfotransferase enzymes in the outer root sheath of hair follicles. Previously, we demonstrated that sulfotransferase activity in hair follicles predicts response to topical minoxidil in the treatment of AGA. In the human liver, sulfotransferase activity is significantly inhibited by salicylic acid. Low-dose OTC aspirin (75-81 mg), a derivative of salicylic acid, is used by millions of people daily for the prevention of coronary heart disease and cancer. It is not known whether oral aspirin inhibits sulfotransferase activity in hair follicles, potentially affecting minoxidil response in AGA patients. In the present study, we determined the follicular sulfotransferase enzymatic activity following 14 days of oral aspirin administration. In our cohort of 24 subjects, 50% were initially predicted to be responders to minoxidil. However, following 14 days of aspirin administration, only 27% of the subjects were predicted to respond to topical minoxidil. To the best of our knowledge, this is the first study to report the effect of low-dose daily aspirin use on the efficacy of topical minoxidil.

Treatment preferences among Japanese women with dysmenorrhea: results from a discrete choice experiment study

PURPOSE

To examine patient preferences for oral and intrauterine system treatments for dysmenorrhea in Japan.

PATIENTS AND METHODS

A discrete choice experiment was conducted to assess the willingness to accept trade-offs among hypothetical treatment profiles. An internet-based survey was administered to women 18-49 years of age who self-reported a dysmenorrhea diagnosis or experienced dysmenorrhea at least once in the past 6 months (N=309). Choice questions included pairs of treatments presented with different attributes: mode of administration, reduction in bleeding after 6 months, chance of symptoms becoming "improved", nausea, weight gain, irregular bleeding, and risk of venous thromboembolism. Relative importance (RI) estimates were computed.

RESULTS

The mean respondent age was 35.8 years (standard deviation =7.0), and 85 women (27.5%) reported that they had previously used hormonal therapy for dysmenorrhea. Treatment preference was most strongly associated with mode of administration (RI=49.8%), followed by chance of irregular bleeding (RI=17.3%). In contrast, treatment preference was most weakly associated with chance of weight gain (RI=2.4%) and reduction in bleeding after 6 months (RI=0.8%). Respondents preferred oral treatments: for twice-daily regimen, odds ratio (OR)=4.90; for once-daily fixed cyclic regimen, OR=4.20; and for once-daily flexible extended regimen, OR=2.44; whereas for intrauterine system, OR=0.02 (p<0.001 for all). Those with prior hormonal therapy experience exhibited the same pattern.

CONCLUSION

Mode of administration factored heavily in dysmenorrhea treatment preferences. Women of reproductive age preferred oral medication, especially twice-daily regimen and once-daily fixed cyclic regimen. Findings can potentially help to improve physician-patient communication and treatment decision making. Physicians should consider factors that can influence patient preference to optimize treatment acceptance and adherence.

The effect of topical minoxidil treatment on follicular sulfotransferase enzymatic activity

Minoxidil is the only US FDA-approved topical drug for the treatment of female and male pattern hair loss. Previously, it was demonstrated that topical minoxidil is metabolized to its active metabolite, minoxidil sulfate, by sulfotransferase enzymes located in the outer root sheath of hair follicles. The expression of sulfotransferase in the scalp varies greatly between individuals, and this difference in expression explains the varied response to minoxidil treatment. Previously, we have demonstrated the clinical utility of detecting sulfotransferase in plucked hair follicles to predict minoxidil response in pattern hair loss patients. Typically, exogenous exposure to substrates affects the expression of the enzymatic system responsible for their metabolism. For example, Phase I metabolizing enzymes, such as the cytochrome P450 family of enzymes, are known to be up-regulated in the presence of xenobiotic substrates. However, it is not known if Phase II metabolizing enzymes, such as the sulfotransferase family of enzymes, are similarly affected by the presence of substrates. In this study, we recruited 120 subjects and analyzed their sulfotransferase enzymatic activity before and after treatment with topical minoxidil. Adjusting the results for biologic (within subject) variability, we discovered that the sulfotransferase enzymatic system expression is stable over the course of minoxidil treatment. To the best of our knowledge, this is the first study to demonstrate the stability of sulfotransferase, a Phase II metabolizing enzyme, over the course of minoxidil treatment.

Alzheimer's disease severity and its association with patient and caregiver quality of life in Japan: results of a community-based survey

BACKGROUND

Alzheimer's disease (AD) dementia, a progressive neurodegenerative disease, exerts significant burden upon patients, caregivers, and healthcare systems globally. The current study investigated the associations between AD dementia patient disease severity and health-related quality of life (HRQoL) of both patients (proxy report) and their caregivers living in Japan, as well as caregiving-related comorbidities such as depression.

METHODS

This cross-sectional study used self-reported data from caregivers of people diagnosed with AD dementia by a healthcare provider in Japan. Caregivers were identified via online panels and invited to participate in an online survey between 2014 and 2015. Caregivers completed survey items for themselves, in addition to providing proxy measures for patients with AD dementia for whom they were caring. Patient and caregiver HRQoL was measured using the EuroQoL 5-Dimension (EQ-5D). Additional outcomes for caregivers of AD dementia patients included the Patient Health Questionnaire (PHQ-9) of depressive symptomology, as well as comorbidities experienced since initiating caregiving for their AD dementia patients. These outcomes were examined as a function of AD dementia severity, as measured by long-term care insurance (LTCI) categories. Bivariate analyses between LTCI and outcomes were conducted using independent t-tests and chi-square tests. Multivariable analyses, controlling for potential confounders, were conducted using generalized linear models (GLMs) specifying a normal distribution.

RESULTS

Across 300 caregiver respondents, multivariable results revealed that increasing AD dementia severity was significantly associated with poorer patient and caregiver EQ-5D scores and a high proportion of caregivers (30.0%) reported PHQ-9 scores indicative of major depressive disorder (MDD). The most frequent comorbidities experienced after becoming caregivers of AD dementia patients included hypertension (12.7%) and insomnia (11.0%). Depression and other comorbidities did not differ significantly by patient severity.

CONCLUSIONS

The current study provides unique insight into the specific degree of incremental burden associated with increasing AD dementia severity among patients and caregivers alike. Importantly, greater disease severity was associated with poorer quality of life among both patients and caregivers. These results suggest that earlier detection and treatment of AD dementia may provide an opportunity to reduce the burden of disease for patients, caregivers, and society at large.

Detection, diagnosis, and treatment of Alzheimer's disease dementia stratified by severity as reported by caregivers in Japan

BACKGROUND

Dementia of Alzheimer's disease (AD) imposes burdens on patients, caregivers, and society. This cross-sectional study examined caregiver-reported history of disease onset and AD dementia to inform efforts promoting early disease detection and diagnosis.

METHODS

An online survey collected self-reported cross-sectional data - demographic characteristics, diagnosis, treatment experiences, and other information on disease detection, diagnosis, and treatment - from caregivers of patients with AD dementia. These characteristics were examined as a function of AD dementia severity.

RESULTS

Three hundred patients with AD dementia were trichotomized by long-term care insurance levels reported by caregivers: 12.3% (n=37) as low severity, 63.7% (n=191) as medium severity, and 24.0% (n=72) as high severity. The Short-Memory Questionnaire and patient dependency scores both varied significantly across severity groups. AD dementia symptoms were most frequently first detected by a caregiver (58.7%) or the patient's family (45.7%). However, in 13.7% of cases, symptoms were detected by a health care provider during a routine visit. Memory problems were the most frequent first symptoms (77.3%), followed by repetition (55.7%). Patients (73.7%) were taking symptomatic treatment such as acetylcholinesterase inhibitors or memantine. High-severity patients were older, had been diagnosed with AD dementia for a longer time, had more frequent reports of memory problems as the first symptoms detected, and required more hours of care per day, compared with low-severity patients.

CONCLUSION

Caregivers and families play an integral role in the identification of AD dementia patients, with memory problems being common first symptoms noticed by caregivers that led to a diagnosis of AD dementia. These results provide novel insight into the detection, diagnosis, and treatment of AD dementia in Japan and how these factors differ across the spectrum of disease severity.

Social selection favours offspring prone to the development of androgenetic alopecia

In recent years, dermatologists have observed an increase in the incidence of male androgenetic alopecia (AGA). In a survey of 41 dermatologists, 88% reported an increase in incidence of AGA in men younger than 30 years. This phenomenon has no apparent explanation. However, due to the strong genetic inheritance component of AGA, a social or environmental factor which favours the inheritance of genes that increase the risk of developing AGA is suspected. To date, the strongest predictor of AGA in men has been the length of the CAG repeat located in the androgen receptor gene (AR gene) on the X chromosome. The same genetic variant in women is associated with ovulation at a later age, higher antral follicle count, and lower risk for premature ovarian failure. This led us to theorize that, due to social pressure to conceive later in life, women carriers of the short CAG repeat in the AR gene would have a selective advantage to conceive later in life and would thus favour male offspring exhibiting AGA.

Mechanism of action of minoxidil in the treatment of androgenetic alopecia is likely mediated by mitochondrial adenosine triphosphate synthase-induced stem cell differentiation

Topical minoxidil is the only topical drug approved by the US Food and Drug Administration (FDA) for the treatment of androgenetic alopecia. However, the exact mechanism by which minoxidil stimulates anagen phase and promotes hair growth is not fully understood. In the late telegen phase of the hair follicle growth cycle, stem cells located in the bulge region differentiate and re-enter anagen phase, a period of growth lasting 2-6 years. In androgenetic alopecia, the anagen phase is shortened and a progressive miniaturization of hair follicles occurs, eventually leading to hair loss. Several studies have demonstrated that minoxidil increases the amount of intracellular Ca2+, which has been shown to up-regulate the enzyme adenosine triphosphate (ATP) synthase. A recent study demonstrated that ATP synthase, independent of its role in ATP synthesis, promotes stem cell differentiation. As such, we propose that minoxidil induced Ca2+ influx can increase stem cell differentiation and may be a key factor in the mechanism by which minoxidil facilitates hair growth. Based on our theory, we provide a roadmap for the development of a new class of drugs for the treatment of androgenetic alopecia.

Potential risk of developing herpes simplex encephalitis in patients treated with sildenafil following primary exposure to genital herpes

Herpes simplex encephalitis (HSE) is associated with significant mortality and morbidity. As a consequence of HSE, up to 75% of infected individuals die or experience irreversible neurological damage. While the pathogenesis of the disease is unknown, it is traditionally hypothesized that the viral infection occurs by neuronal transmission directly from peripheral sites. Non-neuronal modes of infection have generally been overlooked as the brain is protected by the blood-brain-barrier (BBB). The BBB poses an effective barrier to pathogens as well as to drugs such as chemotherapies. In the pursuit to deliver chemotherapeutic agents to the brain, several studies demonstrated that phosphodiesterase type 5 (PDE5) inhibitors, such as sildenafil, may increase the permeability of the BBB enabling successful delivery of chemotherapeutic agents to the brain. In this communication, we report a case of HSE infection in a 62-year-old man, which we suspect was facilitated by the use of sildenafil during a primary genital herpes simple virus (HSV) infection. Due to large number of patients treated with PDE5 inhibitors for erectile dysfunction and the high incidence of genital HSV infection in the general population, a larger study should examine the potential risk of developing HSE in patients treated with PDE5 inhibitors.

Melanin of the nipple areola complex

Biological pigments or biochromes are ubiquitous in animals, plants, and simpler organisms such as fungi and bacteria. They serve a wide spectrum of functions from photosynthesis, camouflage, mimicry, photo protection from the environment to attracting mates. The human female nipple areola complex (NAC) is a highly-pigmented area. Currently, the prevailing theory as to the evolution of the pigmented human NAC is based on infant recognition of breast feeding latching zone; however, due to the protruding shape of the nipple and surrounding breast, the authors of this letter believe that the evolutionary advantage of the pigmented NAC has a direct physiological function, namely the initiation of involution at the end of the infant lactation period.

Minoxidil dose response study in female pattern hair loss patients determined to be non-responders to 5% topical minoxidil

Topical minoxidil is the only US FDA approved drug for the treatment of female pattern hair loss (FPHL). 5% minoxidil foam is only effective at re-growing hair in a minority of women (approximately 40%). Thus, the majority of FPHL patients remain untreated. Previously, we demonstrated that nonresponders to 5% minoxidil have low metabolism of minoxidil in hair follicles. As such, we hypothesized that increasing the dosage of topical minoxidil to low metabolizers would increase the number of responders without increasing the incidence of adverse events. In this study, we recruited FPHL subjects that were identified as non-responders to 5% topical minoxidil utilizing the previously validated assay for minoxidil response. Subjects were treated for 12 weeks with a novel 15% topical minoxidil solution. At 12 weeks, 60% of subjects achieved a clinically significant response based on target area hair counts (>13.7% from baseline), as well as significant improvement in global photographic assessment. None of the subjects experienced significant hemodynamic changes or any other adverse events. To the best of our knowledge, this is the first study to demonstrate the potentially beneficial effect of a higher dosage of minoxidil in FPHL subjects who fail to respond to 5% minoxidil.

Impact of caring for persons with Alzheimer's disease or dementia on caregivers' health outcomes: findings from a community based survey in Japan

Background

This study assessed how family caregivers for patients with Alzheimer’s disease (AD) or dementia in Japan differed from non-caregivers in characteristics and health outcomes (i.e., comorbidities, health-related quality of life [HRQoL], productivity, and resource use). Caregivers were hypothesized to experience significantly poorer outcomes than non-caregivers.

Methods

Data were combined from the 2012 and 2013 National Health and Wellness Survey in Japan (n = 60000). Caregivers for adult relatives with AD or dementia were compared with non-caregivers on: comorbidities (including Patient Health Questionnaire (PHQ-9) cutoff scores suggesting presence/absence of major depressive disorder (MDD)), Work Productivity and Activity Impairment (WPAI), SF-36v2-based HRQoL, and healthcare resource utilization. Sociodemographic characteristics, health characteristics and behaviors, and Charlson comorbidity index (CCI) scores were compared across groups. Propensity matching, based on scores generated from a logistic regression predicting caregiving, was used to match caregivers with non-caregivers with similar likelihood of being caregivers. Bivariate comparisons across matched groups served to estimate outcomes differences due to caregiving.

Results

Among 55060 respondents, compared with non-caregivers (n = 53758), caregivers (n = 1302) were older (52.6 vs. 47.5 years), more frequently female (53 % vs. 49 %), married/partnered, frequent alcohol drinkers, current smokers, exercisers, and not employed, and they averaged higher CCI scores (0.37 vs. 0.14), all p < 0.05. Propensity scores incorporated sex, age, body mass index (BMI), exercise, alcohol, smoking, marital status, CCI, insured status, education, employment, income, and children in household. A greedy matching algorithm produced 1297 exact matches, excluding 5 non-matched caregivers. Health utilities scores were significantly lower among caregivers (0.724) vs. non-caregivers (0.764), as were SF-36v2 Physical and Mental Component Summary scores. Caregivers vs. non-caregivers had significantly higher absenteeism, presenteeism-related impairment, overall work impairment (25.8 % vs. 20.4 %, respectively), and activity impairment (25.4 % vs. 21.8 %), more emergency room and traditional provider visits (7.70 vs. 5.35) in the past six months, and more frequent MDD (14 % vs. 9 %), depression, insomnia, anxiety, and pain.

Conclusions

Those providing care for patients with AD or dementia in Japan experienced significantly poorer HRQoL and greater comorbid risk, productivity impairment, and resource use. These findings inform the need for greater support for caregivers and their patients.

Caregiving for patients with Alzheimer's disease or dementia and its association with psychiatric and clinical comorbidities and other health outcomes in Brazil

OBJECTIVES

Individuals with dementia due to Alzheimer's disease often receive care from family members who experience associated burden. This study provides the first broad, population-based account of caregiving-related health outcome burden in Brazil.

METHODS

Data were analyzed from the 2012 National Health and Wellness Survey in Brazil (n = 12,000), an Internet-based survey of adults (aged 18+ years), using stratified sampling by sex and age to ensure demographic representation of Brazil's adult population. Caregivers of individuals with Alzheimer's disease or dementia were compared with non-caregivers on comorbidities, productivity impairment, health-related quality of life, resource utilization, sociodemographic/health characteristics and behaviors, and Charlson comorbidity index scores. Regression models assessed outcomes associated with caregiving, adjusting for potential confounds.

RESULTS

Among 10,853 respondents, caregivers' (n = 209) average age was 42.1 years, 53% were female, and 52% were married/living with a partner. Caregivers versus non-caregivers (n = 10,644) were more frequently obese, smokers, insured, employed, college-educated, and wealthier and had higher Charlson comorbidity index, all p < 0.05. Adjusting for covariates, caregiving was associated with significantly increased risk of depressive symptoms (odds ratio [OR] = 2.008), major depressive disorder (OR = 1.483), anxiety (OR = 1.714), insomnia (OR = 1.644), hypertension (OR = 1.584), pain (OR = 1.704), and diabetes (OR = 2.103), all p < 0.015. Caregiving was also associated with lower health utilities (-0.024 points) and mental health status (-1.70 points), higher rates of presenteeism-related impairment (32.7% greater) and overall work impairment (35.9% greater), and higher traditional provider visit rates (28.7% greater), all p < 0.035.

CONCLUSIONS

Caregiver status was found to be a factor associated with worse health outcomes and psychiatric and clinical disorders.

Potential benefits of diagnosis and treatment on health outcomes among elderly people with symptoms of overactive bladder

OBJECTIVES

This study examined potential benefits of diagnosing and treating elderly adults with overactive bladder (OAB) symptoms.

METHODS

Data were analysed from the OAB Re-Contact Study (N = 2750), a cross-sectional, self-reported Internet survey. Elderly respondents (65+ years old) with OAB were identified according to current medication use to control OAB symptoms or by scores > 14 (men) or > 16 (women) on the OAB Awareness Tool. Treated were those currently using prescription medication and never treated were those who never used prescription medication for OAB. Outcome measures included health-related quality of life, activity impairment, OAB-related severity and symptoms, and healthcare resource use (e.g. hospitalisations). Generalised linear models predicted health outcomes as a function of diagnosis or treatment, adjusting for covariates.

RESULTS

Diagnosed vs. not diagnosed elderly respondents had higher mental component summary (MCS) scores and SF-6D health utilities, and less activity impairment. Treated vs. never treated elderly respondents had higher MCS and SF-6D health utilities, less activity impairment, fewer OAB symptoms, lower OAB Awareness Tool scores, and lower odds of having bladder problems or incontinence. There were no significant differences in healthcare resource use. Further analysis by age group (middle-aged vs. elderly respondents) revealed significantly greater diagnosis- and treatment-related benefits on MCS (2.93 and 4.49 points more, respectively) and activity impairment (1.24 and 1.37 times as much, respectively) among elderly respondents.

CONCLUSIONS

Diagnosis and treatment were each associated with a lower health burden for elderly adults with OAB symptoms. These findings highlighted the importance of diagnosis and treatment in alleviating OAB symptoms and their impact on health outcomes.

Doppler laser imaging predicts response to topical minoxidil in the treatment of female pattern hair loss

Topical minoxidil is the only drug approved by the US FDA for the treatment of female pattern hair loss. Unfortunately, following 16 weeks of daily application, less than 40% of patients regrow hair. Several studies have demonstrated that sulfotransferase enzyme activity in plucked hair follicles predicts topical minoxidil response in female pattern hair loss patients. However, due to patients’ discomfort with the procedure, and the time required to perform the enzymatic assay it would be ideal to develop a rapid, non-invasive test for sulfotransferase enzyme activity. Minoxidil is a pro-drug converted to its active form, minoxidil sulfate, by sulfotransferase enzymes in the outer root sheath of hair. Minoxidil sulfate is the active form required for both the promotion of hair regrowth and the vasodilatory effects of minoxidil. We thus hypothesized that laser Doppler velocimetry measurement of scalp blood perfusion subsequent to the application of topical minoxidil would correlate with sulfotransferase enzyme activity in plucked hair follicles. In this study, plucked hair follicles from female pattern hair loss patients were analyzed for sulfotransferase enzyme activity. Additionally, laser Doppler velocimetry was used to measure the change in scalp perfusion at 15, 30, 45, and 60 minutes, after the application of minoxidil. In agreement with our hypothesis, we discovered a correlation (r=1.0) between the change in scalp perfusion within 60 minutes after topical minoxidil application and sulfotransferase enzyme activity in plucked hairs. To our knowledge, this is the first study demonstrating the feasibility of using laser Doppler imaging as a rapid, non-invasive diagnostic test to predict topical minoxidil response in the treatment of female pattern hair loss.

Openness to and preference for attributes of biologic therapy prior to initiation among patients with rheumatoid arthritis: patient and rheumatologist perspectives and implications for decision making

PURPOSE

Despite American College of Rheumatology recommendations, appropriate and timely initiation of biologic therapies does not always occur. This study examined openness to and preference for attributes of biologic therapies among patients with rheumatoid arthritis (RA), differences in patients' and rheumatologists' perceptions, and discussions around biologic therapy initiation.

PATIENTS AND METHODS

A self-administered online survey was completed by 243 adult patients with RA in the US who were taking disease-modifying antirheumatic drugs (DMARDs) and had never taken, but had discussed biologic therapy with a rheumatologist. Patients were recruited from a consumer panel (n=142) and patient advocacy organization (n=101). A separate survey was completed by 103 rheumatologists who treated at least 25 patients with RA per month with biologic therapy. Descriptive and bivariate analyses were conducted separately for patients and rheumatologists. Attributes of biologic therapy included route of administration (intravenous infusion or subcutaneous injection), frequency of injections/infusions, and duration of infusion.

RESULTS

Over half of patients (53.1%) were open to both intravenous infusion and subcutaneous injection, whereas rheumatologists reported 40.7% of patients would be open to both. Only 26.3% of patients strongly preferred subcutaneous injection, whereas rheumatologists reported 35.2%. Discrepancies were even more pronounced among specific patient types (eg, older vs younger patients and Medicare recipients). Among patients, 23% reported initiating discussion about biologics and 54% reported their rheumatologist initiated the discussion. A majority of rheumatologists reported discussing in detail several key aspects of biologics, whereas a minority of patients reported the same.

CONCLUSION

Preferences differed among patients with RA from rheumatologists' perceptions of these preferences for biologic therapy, including greater openness to intravenous infusion among patients than assumed by rheumatologists and relative lack of discussion about key aspects of biologic therapy perceived by patients. There is a need for more open communication about treatment options, which may encourage more appropriate, timely transition to biologic therapy.

Treatment satisfaction among men with concurrent benign prostatic hyperplasia and erectile dysfunction treated with tadalafil or other phosphodiesterase type-5 inhibitor combinations

OBJECTIVE

Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) frequently co-occur in men aged ≥40, along with lower urinary tract symptoms (LUTS) secondary to BPH. Given little real-world evidence on treatment use or satisfaction with treatment for concurrent BPH/LUTS and/or ED, this study examined medication regimens and differences in satisfaction and health-related quality of life (HRQoL) across regimens among men with concurrent BPH and ED.

METHODS

A cross-sectional study was conducted using an Internet survey of participants recruited through an online panel. Respondents (N=736) included men (aged ≥40) who self-reported a diagnosis of both ED and BPH with prescription treatment in the past 3 months for both conditions. Treatment satisfaction (eg, convenience and ease of planning) and HRQoL (eg, International Prostate Symptom Score, sleep quality) were self-reported. Generalized linear models examined the association of regimen with treatment satisfaction and HRQoL, adjusting for covariates (eg, age and comorbidities).

RESULTS

Final analyses included participants (N=507) using: tadalafil once-daily monotherapy (22%), tadalafil for ED with an alternate BPH therapy (36%), or another phosphodiesterase type-5 inhibitor (PDE5-I) combination (41%). These groups represented the major categories of treatment regimens found in the sample, excluded participants with ambiguous regimens, and were aligned with current standard of care for BPH and ED. Overall, patients reported moderate levels of BPH and a moderate-to-severe degree of ED. Tadalafil monotherapy patients had higher treatment satisfaction scores and greater reported ease of treatment planning and convenience than PDE5-I combination patients. No significant intergroup differences were found on HRQoL.

CONCLUSION

A majority of patients (59%) took tadalafil alone or in combination for BPH/ED treatment. Tadalafil monotherapy patients reported greater treatment satisfaction than patients taking PDE5-I combination therapy. Higher satisfaction for both effectiveness and convenience of once-daily tadalafil may inform both patient and clinician decisions regarding pharmacotherapy regimens.

Characterizing patients with psoriasis on injectable biologics adalimumab, etanercept, and ustekinumab: A chart review study

OBJECTIVE

This study examined plaque psoriasis (PsO) patient characteristics across injectable biologics.

METHODS

Data were collected from 400 US dermatologists randomly selecting five charts each for patients with PsO (patient n  =  2000): adalimumab (ADA; n  =  447), etanercept (ETA; 539), ustekinumab (UST) 45 mg (511) and UST 90 mg (503). Physicians had to have been in practice 2-30 years, managing 10+  patients (5 + with biologics for PsO). Generalized estimating equation models, weighted according to inverse probability of patient selection and accounting for patient correlation within physicians, examined patient measures as a function of treatment (UST 90 mg = reference).

RESULTS

Patients on UST 90 mg had higher odds of weighing  >100 kg (adjusted mean  =  34.4%) vs. ADA (10.9%), ETA (5.5%) or UST 45 mg (6.8%), greater body surface affected and higher odds of severe PsO prior to treatment and higher odds of prior biologics use. Mean prior biologics used was higher with UST 90 mg versus ADA or ETA. Number of comorbidities was higher with UST 90 mg versus ETA or UST 45 mg.

CONCLUSIONS

Among biologics-treated patients with PsO, UST 90 mg appears to be used in patients with greater weight, baseline severity and prior biologics experience than ADA, ETA or UST 45 mg. UST 90 mg is used in patients with more comorbidities than other treatments except ADA.

Caregiver burden, productivity loss, and indirect costs associated with caring for patients with poststroke spasticity

Objective

Many stroke survivors experience poststroke spasticity and the related inability to perform basic activities, which necessitates patient management and treatment, and exerts a considerable burden on the informal caregiver. The current study aims to estimate burden, productivity loss, and indirect costs for caregivers of stroke survivors with spasticity.

Methods

Internet survey data were collected from 153 caregivers of stroke survivors with spasticity including caregiving time and difficulty (Oberst Caregiver Burden Scale), Work Productivity and Activity Impairment measures, and caregiver and patient characteristics. Fractional logit models examined predictors of work-related restriction, and work losses were monetized (2012 median US wages).

Results

Mean Oberst Caregiver Burden Scale time and difficulty scores were 46.1 and 32.4, respectively. Employed caregivers (n=71) had overall work restriction (32%), absenteeism (9%), and presenteeism (27%). Caregiver characteristics, lack of nursing home coverage, and stroke survivors’ disability predicted all work restriction outcomes. The mean total lost-productivity cost per employed caregiver was US$835 per month (>$10,000 per year; 72% attributable to presenteeism).

Conclusion

These findings demonstrate the substantial burden of caring for stroke survivors with spasticity illustrating the societal and economic impact of stroke that extends beyond the stroke survivor.