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Husereau D, Drummond M, Augustovski F, Briggs AH, Carswell C, Caulley L, Chaiyakunapruk N, de Bekker-Grob E, Greenberg D, Loder E, Mauskopf J, Mullins CD, Petrou S, Pwu RF, Staniszewska S. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BJOG 2022; 129:336-344. [PMID: 35014160 DOI: 10.1111/1471-0528.17012] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Health economic evaluations are comparative analyses of alternative courses of action in terms of their costs and consequences. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, published in 2013, was created to ensure health economic evaluations are identifiable, interpretable, and useful for decision making. It was intended as guidance to help authors report accurately which health interventions were being compared and in what context, how the evaluation was undertaken, what the findings were, and other details that may aid readers and reviewers in interpretation and use of the study. The new CHEERS 2022 statement replaces previous CHEERS reporting guidance. It reflects the need for guidance that can be more easily applied to all types of health economic evaluation, new methods and developments in the field, as well as the increased role of stakeholder involvement including patients and the public. It is also broadly applicable to any form of intervention intended to improve the health of individuals or the population, whether simple or complex, and without regard to context (such as health care, public health, education, social care, etc). This summary article presents the new CHEERS 2022 28-item checklist and recommendations for each item. The CHEERS 2022 statement is primarily intended for researchers reporting economic evaluations for peer reviewed journals as well as the peer reviewers and editors assessing them for publication. However, we anticipate familiarity with reporting requirements will be useful for analysts when planning studies. It may also be useful for health technology assessment bodies seeking guidance on reporting, as there is an increasing emphasis on transparency in decision making.
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Affiliation(s)
- D Husereau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Institute of Health Economics, Edmonton, AB, Canada
| | - M Drummond
- Centre for Health Economics, University of York, York, UK
| | - F Augustovski
- Health Technology Assessment and Health Economics Department of the Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina.,University of Buenos Aires, Buenos Aires, Argentina.,CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - A H Briggs
- London School of Hygiene and Tropical Medicine, London, UK
| | - C Carswell
- Adis Journals, Springer Nature, Auckland, New Zealand
| | - L Caulley
- Department of Otolaryngology - Head & Neck Surgery, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program and Center for Journalology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - N Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - E de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - D Greenberg
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, School of Public Health, Israel
| | - E Loder
- Harvard Medical School, Boston, MA, USA.,The BMJ, London, UK
| | - J Mauskopf
- RTI Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - C D Mullins
- School of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA
| | - S Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - R-F Pwu
- National Hepatitis C Program Office, Ministry of Health and Welfare, Taipei City, Taiwan
| | - S Staniszewska
- Warwick Research in Nursing, University of Warwick Warwick Medical School, Warwick, UK
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Edwards HA, Huang J, Jansky L, Mullins CD. What works when: mapping patient and stakeholder engagement methods along the ten-step continuum framework. J Comp Eff Res 2021; 10:999-1017. [PMID: 34082571 DOI: 10.2217/cer-2021-0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study provides a recommended 'patient engagement translation table' that identifies evidence-based methods for meaningful patient engagement along a ten-step framework for continuous engagement. Materials & methods: We used a mixed methods research design to collect data on preferred engagement methods, including an environmental scan of available literature, interviews and focus groups with patient-centered outcomes research stakeholders to match methods with research steps and a modified Delphi process with subject matter experts to create the final translation table. Results: Evidence-based engagement methods included community partnerships, focus groups, interviews, meetings, sharing print materials, social media, storytelling, surveys and including patients as research team members. Conclusion: Our recommended patient engagement translation table is designed to assist investigators in determining appropriate engagement methods for meaningful interactions with stakeholders.
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Affiliation(s)
- Hillary A Edwards
- School of Pharmacy, University of Maryland, 220 Arch St. 12th Floor, Baltimore, MD 21201, USA
| | | | - Liz Jansky
- Westat, 1600 Research Blvd, Rockville, MD 20850, USA
| | - C D Mullins
- School of Pharmacy, University of Maryland, 220 Arch St. 12 Floor, Baltimore, MD 21201, USA
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Ng X, dosReis S, Beardsley R, Magder L, Mullins CD, Petri M. Understanding systemic lupus erythematosus patients' desired outcomes and their perceptions of the risks and benefits of using corticosteroids. Lupus 2017; 27:475-483. [PMID: 28857718 DOI: 10.1177/0961203317726375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction The use of corticosteroids in systemic lupus erythematosus (SLE) patients requires difficult trade-offs between efficacy and risk of toxicity. This qualitative study examined SLE patients' most desired outcomes and their concerns with corticosteroid use in SLE treatment. Methods SLE patients with current/past experience with using corticosteroids were recruited from the clinics at the Johns Hopkins Lupus Center and the University of Maryland Medical Center. Five in-depth interviews ( N = 5) and four focus groups ( N = 15) were conducted during which discussions were transcribed and analyzed based on a grounded theory approach. Results We identified five major themes describing SLE patients' most desired outcomes: reduction in flares, maintenance of normal activities, minimization of treatment side effects, prevention of future organ damage, and finding a cure. Further, SLE patients reported these primary concerns with the adverse effects of corticosteroids: weight gain, organ damage (particularly bone-related damage), mood swings/irritability, sleep disturbances, and dental issues. Patients appeared to be more concerned with adverse effects that immediately affected their day-to-day lives. Conclusion Knowledge gained during this study better informs how patients view the benefits and risks of corticosteroids. This can facilitate discussions between physicians and patients as they work together to determine the appropriate use of corticosteroids.
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Affiliation(s)
- X Ng
- 1 Department of Pharmaceutical Health Services Research, 12265 University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - S dosReis
- 1 Department of Pharmaceutical Health Services Research, 12265 University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - R Beardsley
- 1 Department of Pharmaceutical Health Services Research, 12265 University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - L Magder
- 2 Department of Epidemiology and Public Health, 12265 University of Maryland School of Medicine, Baltimore, MD, USA
| | - C D Mullins
- 1 Department of Pharmaceutical Health Services Research, 12265 University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - M Petri
- 3 Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Rycroft C, Hirst M, Dunlop W, Pirk O, Mullins CD, Akehurst R. Endpoints in Pain: the Suitability for Health Economic Evaluation of Endpoint Designs in Chronic Pain Studies. Value Health 2014; 17:A545. [PMID: 27201765 DOI: 10.1016/j.jval.2014.08.1766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - M Hirst
- Mundipharma International Limited, Cambridge, UK
| | - W Dunlop
- Mundipharma International Limited, Cambridge, UK
| | - O Pirk
- Olaf Pirk Consult, Nürnberg, Germany
| | - C D Mullins
- University of Maryland School of Pharmacy, Baltimore, MD, USA
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Jayasekera J, Onukwugha E, Bikov K, Mullins CD, Seal B, Hussain A. The economic burden of skeletal-related events among elderly men with metastatic prostate cancer. Pharmacoeconomics 2014; 32:173-191. [PMID: 24435407 DOI: 10.1007/s40273-013-0121-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Advanced prostate cancer patients with bone metastasis are predisposed to skeletal complications termed skeletal-related events (SREs). There is limited information available on Medicare costs associated with treating SREs. The objective of this study was to ascertain SRE-related costs among older men with metastatic prostate cancer in the US. METHODS We analysed patients aged 66 years or older who were diagnosed with incident stage IV (M1) prostate cancer between 2000 and 2007 from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare dataset. A propensity score for the incidence of an SRE was estimated using a logistic regression model including demographic and clinical baseline variables. Patients with SREs (cases) were matched to patients without SREs (controls) based on the propensity score, length of follow-up (i.e. date of prostate cancer diagnosis to last date of observation) and death. Health resource utilization cost differences between cases and controls over time were compared using generalized linear models. Healthcare costs were examined by type of SRE (pathological fracture only, pathological fracture with concurrent surgery, spinal cord compression only, spinal cord compression with concurrent surgery, and bone surgery only) and by source of care (inpatient, physician/non-institutional provider, skilled nursing facility, outpatient and hospice). All costs were adjusted to 2009 US dollars, using the medical care component of the Consumer Price Index. RESULTS Application of the inclusion criteria resulted in 1,131 metastatic prostate cancer patients with SREs and 6,067 patients without SREs during follow-up. The average age of the sample was 79 years, and 14 % were African American. A total of 928 patients with SREs were matched to 928 patients without SREs. The average health care utilization cost of patients with SREs was US$29,696 (95 % confidence interval [CI] US$24,730-US$34,662) higher than that of the controls. The most expensive SRE group was spinal cord compression with concurrent surgery (US$82,868: 95 % CI US$67,472-US$98,264) followed by bone surgery only (US$37,496: 95 % CI US$29,684-US$45,308), pathological fracture with concurrent surgery (US$34,169: 95 % CI US$25,837-US$ 42,501), spinal cord compression only (US$25,793: 95 % CI US$20,933-US$30,653) and pathological fracture only (US$14,649: 95 % CI US$6,537-US$22,761). The largest cost difference by source of care was observed for hospitalizations (p < 0.01). CONCLUSION Metastatic prostate cancer patients with SREs incur higher costs compared to similar patients without SREs. SRE costs among older stage IV (M1) prostate cancer patients vary by SRE type, with spinal cord compression and concurrent surgery costing at least twice as much as other SREs.
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Affiliation(s)
- J Jayasekera
- University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, Baltimore, MD, 21201, USA,
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Hanna NN, Onukwugha E, Choti MA, Davidoff AJ, Zuckerman IH, Hsu VD, Mullins CD. Comparative analysis of various prognostic nodal factors, adjuvant chemotherapy and survival among stage III colon cancer patients over 65 years: an analysis using surveillance, epidemiology and end results (SEER)-Medicare data. Colorectal Dis 2012; 14:48-55. [PMID: 21689262 DOI: 10.1111/j.1463-1318.2011.02545.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIM The prognostic effects of chemotherapy and various lymph node measures [positive nodes, total node count and the positive lymph node ratio (PLNR)] have been established. It is unknown whether the cancer-specific survival benefit of chemotherapy differs across these nodal prognostic categories. METHOD This retrospective analysis of linked Surveillance, Epidemiology and End Results (SEER) data and Medicare data (SEER-Medicare)included patients ≥ 65 years of age with a diagnosis of stage III colon cancer between 1997 and 2002. We grouped patients according to the number of positive nodes (N1 and N2), total node count (≥ 12 and < 12 total nodes) and PLNR (below the 75th percentile and at least at the 75th percentile of the PLNR). The end point was colon cancer-specific mortality. RESULTS Fifty-one per cent (3701) of the 7263 patients received adjuvant therapy during the time period 1997-2002. The mean (standard deviation) number of total nodes examined was 13 (9) and the number of positive nodes identified was 3 (3). Patients with N2 disease, < 12 total nodes examined and a high PLNR had a worse survival at 2, 3 and 5 years following colectomy. Utilization of chemotherapy demonstrated a colon cancer-specific survival benefit (hazard ratio at median follow up = 0.7; P < 0.001) that was consistent and statistically significant across the three nodal prognostic categories examined. CONCLUSION The benefit of chemotherapy did not vary based on N stage, total node count or PLNR. The results favour a broad-based approach towards increasing the chemotherapy treatment rates in stage III patients of ≥ 65 years of age, rather than an approach that targets clinical subgroups.
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Affiliation(s)
- N N Hanna
- Department of Surgery, University of Maryland, Baltimore, Maryland 21201, USA.
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Tiglao MR, Phurrough S, Mullins CD, Abernethy AP, Tunis SR. Development of effectiveness guidance documents (EGDs) as a stakeholder-driven process for informing study designs for comparative effectiveness research (CER). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e16617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Onukwugha E, Mullins CD, Grabner M, Hussain A. Radiation oncologist visits and the effect on prostate cancer (PCa) survival among SEER-Medicare patients with stage IV disease. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e15117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mullins CD, Bikov KA, McNally DL, Onwudiwe NC, Dalal MR, Hanna N. Effect of VTE on mortality in patients with stage III colon cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.3620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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10
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Basch EM, Abernethy AP, Mullins CD, Tiglao MR, Tunis SR. Development of a guidance for including patient-reported outcomes (PROs) in post-approval clinical trials of oncology drugs for comparative effectiveness research (CER). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.6000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Montgomery R, Mullins CD, Abernethy AP, Hussain A, Tunis SR. Recommendations for designing comparative effectiveness studies in oncology. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e16550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Rattinger GB, Mullins CD, Zuckerman IH, Onukwugha E, Delisle S. Clinic visits and prescribing patterns among Veterans Affairs Maryland Health Care System dementia patients. J Nutr Health Aging 2010; 14:677-83. [PMID: 20922345 DOI: 10.1007/s12603-010-0315-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our objective was to determine how patient demographics and outpatient referrals to specialized dementia (DEM) or mental health (MH) clinics influence receipt of anti-dementia (AD), antidepressant (ADEP), antipsychotic (APSY) and sedative-hypnotic (SEDH) medications among veterans with dementia. DESIGN Retrospective, cross-sectional observational study. SETTING Veterans Affairs Maryland Health Care System (VAMHCS). PARTICIPANTS Veterans aged ≥ 60 years with Alzheimer's or related dementia diagnosis after 1999 with minimum of one-year follow-up or death were included. MEASUREMENTS Retrospective analysis of VAMHCS electronic medical records were used to determine predictors of AD, ADEP, APSY, and SEDH prescribing using logistic regression models that examined visits to DEM or MH clinics, patient age, follow-up time, race/ethnicity and marital status. RESULTS Among 1209 veterans with average follow-up of 3.2 (SD 1.9) years, 36% percent had MH visits, 38% had DEM visits and 19% visited both clinics. DEM visits were associated with AD and ADEP but not APSY medication receipt (OR(AD:DEM) = 1.47, 95% CI = (1.052, 2.051); OR(ADEP:DEM) = 1.66, 95% CI = (1.193, 2.302); OR(APSY:DEM) = 1.35, 95% CI = (0.941, 1.929)). MH visit was associated with ADEP and APSY medication receipt (OR(AD:MH)\ = 1.16, 95% CI = (0.821, 1.631); OR(ADEP:MH) = 2.83, 95% CI = (2.005, 4.005); OR (APSY:MH) = 4.41, 95% CI = (3.109, 6.255)). CONCLUSION In the VAMHCS dementia population, visits to DEM or MH specialty clinics increase the odds of receiving AD, ADEP, and APSY medications.
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Affiliation(s)
- G B Rattinger
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Lepisto EM, Tangirala K, Vandergrift JL, McClure JS, McNally DL, Mullins CD, Seal BS. Concordance to National Comprehensive Cancer Network (NCCN) clinical practice guideline (GL) drug therapy recommendations for metastatic breast cancer: An analysis from the commercial managed care claims database PharMetrics (PM). J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Pandya NB, Mullins CD, Hsiao FS, Onukwugha E, Seal BS, Hanna N. Comparative effectiveness of adjuvant oxaliplatin and irinotecan-based chemotherapy regimens among elderly stage III colon cancer patients completing 12 cycles. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.e14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Onukwugha E, Grabner M, Mullins CD, Seal BS, Hussain A. Patterns of use of docetaxel in stage IV prostate cancer (PCa) patients in SEER-Medicare. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.4658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mullins CD, Bikov KA, Onwudiwe NC, Seal BS, Hanna N. Incidence of diagnosed VTE among elderly Americans in the year following stage III or IV colon cancer diagnosis. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.3603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Hsiao FS, Mullins CD, Pandya NB, Onukwugha E, Seal BS, Hanna N. Oxaliplatin- or irinotecan-based combination therapy versus 5-fluorouracil/leucovorin alone in the treatment of advanced colon cancer patients age 66 and older: An analysis using SEER-Medicare data. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.3613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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McNally DL, Seal BS, Vandergrift JL, Mullins CD, Lepisto EM, McClure JS, Tangirala M. Concordance to National Comprehensive Cancer Network (NCCN) clinical practice guidelines (GL) for imaging work-up of patients with metastatic breast cancer: An analysis from the commercial managed care claims PharMetrics (PM) and SEER/Medicare (SM) databases. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.1104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Zuckerman IH, Onukwugha E, Gardner JF, McNally DL, Seal BS, Mullins CD. Characteristics of triple-negative metastatic breast cancer among older adults: A population-based analysis. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.1092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Grabner M, Onukwugha E, Mullins CD, Seal BS, Hussain A. Who receives chemotherapy: An analysis of stage IV prostate cancer (PCa) patients in SEER-Medicare. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.4655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hsiao FY, Mullins CD. The association between thiazolidinediones and hospitalisation for fracture in type 2 diabetic patients: a Taiwanese population-based nested case-control study. Diabetologia 2010; 53:489-96. [PMID: 19943156 DOI: 10.1007/s00125-009-1609-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 10/29/2009] [Indexed: 10/20/2022]
Abstract
AIMS/HYPOTHESIS Evidence from the USA has emerged that thiazolidinediones may have a negative effect on the skeleton and increase the risk of fracture, but the association between thiazolidinediones use and fractures has not been evaluated in an Asian population. Using the 2000-2005 Taiwan National Health Insurance claims database, this Taiwanese population-based nested case-control study explored the association between thiazolidinediones use and hospitalisation for bone fracture in type 2 diabetic patients. METHODS In the study cohort of type 2 diabetic patients, we identified 18,003 patients with fracture and 90,015 matched controls. Multivariable conditional logistic regressions were used to estimate the association between exposure to thiazolidinediones and fractures. Duration of thiazolidinediones use was defined on the basis of cumulative days of exposure to thiazolidinediones during the year prior to the index date, i.e. <30 days, 30 to 180 days and >180 days. RESULTS More type 2 diabetic patients with fractures than controls used thiazolidinediones (fractures 5.99% vs control 4.06%). Thiazolidinediones use was associated with hospitalisation for fracture and the association was stronger with longer term exposure to thiazolidinediones (<30 days OR 1.32 [95% CI 1.09-1.54], p = 0.005; 30-180 days 1.42 [1.24-1.62], p < 0.0001; and >180 days 1.54 [1.37-1.74], p < 0.0001). This dose-response relationship was significantly evident in women (<30 days, 1.20 [0.93-1.55], p = 0.17; 30-180 days, 1.57 [1.32-1.86], p < 0.0001; and >180 days, 1.76 [1.52-2.04], p < 0.0001), but not in men. CONCLUSIONS/INTERPRETATION Long-term exposure of type 2 diabetic patients to thiazolidinediones was associated with higher odds of fractures among women without a significant increase in odds of fractures among men.
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Affiliation(s)
- F-Y Hsiao
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, Baltimore, MD 21201, USA.
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Hussain A, Onukwugha E, Seal B, Mullins CD. Visit and treatment patterns over time among elderly patients (pts) with M1 prostate cancer (PC): An analysis using SEER-Medicare. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.5170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5170 Background: Treatment options for the management of pts diagnosed with M1 PC have evolved over time. It is unknown whether visits to medical oncologists/hematologist oncologists (MOH) and treatment patterns are also changing over time. The objective of this study is to examine changes in visit and treatment patterns over time. Methods: A retrospective analysis of SEER Medicare data included pts diagnosed with M1 PC from 1994–2002 (age > 65 years) and residing in SEER registries that were present for the entire period. The study included pts with a post-diagnosis visit to a urologist; pts who saw a MOH prior to the urologist visit were excluded. Pts were grouped as 1) no MOH visit, 2) MOH visit w/in 3 mos of a urologist visit, 3) MOH visit => 3 mos after a urologist visit. Treatment with hormone therapy or chemotherapy was defined as 1) none received; 2) timely (i.e. within 6 mos of diagnosis); and 3) delayed, i.e. => 6 mos following the diagnosis. Time periods were defined as early (1994–1996), middle (1997–1999) and late (2000–2002). Results: 3,269 pts (mean age 77, 81% white) were available for analysis. Ninety-three percent of pts received treatment. Thirty-eight percent of pts saw a MOH during the study period; over the study period (early; middle; late) 13% (10%; 13%; 17%) of pts had a timely visit to the MOH and 25% (24%; 28%; 25%) had a delayed visit to the MOH. The proportion of patients seeing a MOH increased (34%; 41%; 42%, p < 0.001) and the proportion of treated pts increased (93%; 93%; 95%, p = 0.03) over the early, middle, and late periods. Conclusions: Approximately one-third of patients with M1 disease and a post-diagnosis urologist visit also see a medical oncologist. The vast majority of these patients receive treatment. Over time, a larger proportion of patients are seeing medical oncologists. [Table: see text]
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Affiliation(s)
- A. Hussain
- University of Maryland Cancer Center, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ
| | - E. Onukwugha
- University of Maryland Cancer Center, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ
| | - B. Seal
- University of Maryland Cancer Center, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ
| | - C. D. Mullins
- University of Maryland Cancer Center, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ
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Boklage SH, Chen L, Christiansen NP, Sullivan SD, Hay JW, Mullins CD. Use of growth factors associated with docetaxel and paclitaxel in patients with early-stage breast cancer in a community oncology center. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17548 Background: Docetaxel and paclitaxel are widely used in treating breast cancer (BC), and both have hematologic toxicity commonly managed by costly growth factors (GFs). However, the extent of GFs use in real-world clinical practice has not been well documented. Methods: The Georgia Oncology Specialist Database was used and contained chemotherapy, medical and pharmacy claims, and lab results for nearly 170,000 patients with various types of cancer (2003–2008). Patients with stage I-III BC receiving docetaxel- or paclitaxel-containing regimens as adjuvant therapy were followed from 1 week prior to docetaxel or paclitaxel (index drug) initiation to the earliest of death, loss to follow-up, switch in taxane, or end of 90-day period post last dose of index drug. Incidence of GFs use per person-year was compared using univariate negative binomial (NB) model, median time to first GFs use was compared using Wilcoxon test. Multivariate analyses were performed on number of utilizations and time to first utilization adjusting for potential confounders. Results: Compared with paclitaxel (n = 433), docetaxel cohort (n = 216) had lower incidence per person-year of erythroid stimulating agents (ESAs) use (8.01 vs. 11.72, p = 0.008), while similar incidence of myeloid growth factors (MGFs) use (8.51 vs. 5.07, p = 0.541). Lower MGFs utilization in docetaxel patients (ratio of number of utilization = 0.821, p = 0.033), and similar ESAs utilization (ratio of number of utilization = 0.920, p = 0.305) were found. While descriptive analysis showed paclitaxel patients received first ESAs sooner than docetaxel patients (median length: 23 vs. 7 days, p < 0.001), and no difference in time to first MGFs use (median 8 days for both); multivariate analyses found docetaxel patients received first MGFs sooner (ratio of days = 0.828, p = 0.039), and no difference in time to first ESAs use (ratio of days = 1.091, p = 0.419). Conclusions: This analysis suggests that docetaxel is associated with lower utilization of MGFs. Studies examining the economic impact of GFs use associated with taxanes will need to be conducted. A potential limitation of this study is that the potential selection bias may not be fully adjusted. [Table: see text]
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Affiliation(s)
- S. H. Boklage
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
| | - L. Chen
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
| | - N. P. Christiansen
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
| | - S. D. Sullivan
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
| | - J. W. Hay
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
| | - C. D. Mullins
- PrO Unlimited, Boca Raton, FL; sanofi-aventis US, Bridgwater, NJ; South Carolina Oncology Associates, Columbia, SC; University of Washington, Seattle, WA; University of Southern California, Los Angeles, CA; University of Maryland, Baltimore, MD
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Onukwugha E, Mullins CD, Obeidat N, Seal B, Hussain A. The impact of docetaxel (D) in an older population of patients with advanced prostate cancer (PC): A simulation study using TAX327 and SEER Medicare data. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e16074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16074 Background: The survival benefit of D in treatment of hormone refractory PC (HRPC) has been established in the TAX327 trial, but it is unclear how this benefit would translate in a heterogeneous population. This study sought to simulate the survival impact of D in a population of older pts with M1 PC on androgen deprivation therapy (ADT). Methods: A combination of TAX327 trial data and SEER-Medicare (SM) data were used. In pts age 69+ and randomized to D (every 3 weeks, D3P) or mitoxantrone (M), trial data showed a survival benefit for D. Accordingly, SM pts age 69+ diagnosed with M1 PC between 1994 and 2002 and receiving only ADT were selected. Graphical plots and statistical tests were used to find best-fitting parametric survival functions for D3P, M, and SM pts. The survival benefit for D was imposed on unadjusted and covariate-adjusted SM survival curves. The simulated benefit was assessed at 12 mos and 24 mos post-diagnosis of M1 PC in SM pts. Results: There were 326 TAX327 trial pts (D3P = 159, M = 167) used in the analysis. Median survival was 15.7 mos (12.6 - 19) in the M arm and 18.9 mos [17 - 21.8] in the D3P arm (p = 0.03). There were 3,515 SM pts, based on inclusion criteria. Median survival benefit of D was 3.2 mos based on Kaplan-Meier estimates and 2.4 mos using parametric curves in the TAX327 69+ group. Following covariate-adjustment in the SM sample, at 12 mos post-diagnosis, the median survival in mos was 61.7 (CI 36.3 - 87) in the ADT group and 62 (CI 37.6 - 87.1) in the simulated ADT+D group (i.e., 0.3 mos simulated benefit of D). A 0.8 mos simulated benefit was found if D was initiated 24 mos post diagnosis (in pts more likely to have HRPC). Conclusions: The survival benefit of docetaxel from the TAX327 trial is attenuated in a heterogeneous SEER-Medicare sample, and the simulated survival benefit is larger among patients who are more likely to have hormone refractory prostate cancer. [Table: see text]
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Affiliation(s)
- E. Onukwugha
- University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, LLC, Bridgewater, NJ; University of Maryland School of Medicine, Baltimore, MD
| | - C. D. Mullins
- University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, LLC, Bridgewater, NJ; University of Maryland School of Medicine, Baltimore, MD
| | - N. Obeidat
- University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, LLC, Bridgewater, NJ; University of Maryland School of Medicine, Baltimore, MD
| | - B. Seal
- University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, LLC, Bridgewater, NJ; University of Maryland School of Medicine, Baltimore, MD
| | - A. Hussain
- University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, LLC, Bridgewater, NJ; University of Maryland School of Medicine, Baltimore, MD
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Obeidat NA, Mullins CD, Onukwugha E, Seal B, Hussain A. Characteristics of elderly metastatic prostate cancer (M1 PC) long-term survivors in the SEER Medicare database receiving androgen-deprivation therapy (ADT). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17513 Background: ADT remains standard treatment for pts with M1 PC, with radiation (RT) and chemotherapy (CT) providing additional palliation. This population-based analysis evaluated if long-term survivors (LT) receiving ADT possessed different characteristics relative to short-term survivors (ST). Methods: Pts age >/= 66y in SEER Medicare diagnosed with M1 PC between 1998 and 2002 and receiving ADT with or without subsequent CT were identified. Median overall survival (OS) for the sample was used as a cut-off to categorize ST and LT pts. Within these categories, demographic, and clinical characteristics were evaluated. Results: 2,665 ADT pts were first identified who had median OS of 26 months (95% CI 24.0 - 27.0). 1,349 pts died at </= 26 months (ST pts), while 1,245 pts survived or were lost to follow-up beyond 26 months (LT pts). Median time to first treatment with ADT was 1 mo in both ST and LT groups. Within this 66y+ population, LT pts were younger (p < 0.0001), more likely to be married (p = 0.0277), and were comprised of lower % of non-Hispanic white pts and higher % of ‘other’ races, but comparable % of African American and White-Hispanics (p = 0.0005). Distributional differences in PSA were detected, but interpreting the results was difficult due to missing or unknown information. Both ST and LT pts received RT and prostatectomy at similar rates, but LT pts had less comorbidities (p = 0.0008), and were more likely to receive CT (p = 0.0026). Conclusions: Long-term survivors were found to have demographic and clinical characteristics that differed from short-term survivors. Evidence regarding how these characteristics simultaneously impact the type and timing of treatment as well as survival deserve more exploration. [Table: see text]
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Affiliation(s)
- N. A. Obeidat
- University of Maryland, Baltimore, MD; Sanofi- aventis, Whitehouse Station, NJ
| | - C. D. Mullins
- University of Maryland, Baltimore, MD; Sanofi- aventis, Whitehouse Station, NJ
| | - E. Onukwugha
- University of Maryland, Baltimore, MD; Sanofi- aventis, Whitehouse Station, NJ
| | - B. Seal
- University of Maryland, Baltimore, MD; Sanofi- aventis, Whitehouse Station, NJ
| | - A. Hussain
- University of Maryland, Baltimore, MD; Sanofi- aventis, Whitehouse Station, NJ
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Mullins CD, Onukwugha E, Seal B, Hussain A, Hussain A. The impact of time of medical oncologist visit on survival among elderly patients with stage IV prostate cancer: An analysis using SEER-Medicare data. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17509 Background: The association between physician referrals and treatment receipt has been established in other disease settings. The impact of time to a medical oncologist or hematologist/oncologist (MOH) visit on survival has not been examined in patients (pts) with advanced prostate cancer (A-PC). The objective of this study is to determine whether the time to a MOH visit is associated with survival. Methods: The SEER-Medicare database was used for the analysis. Pts aged >65 diagnosed with A-PC between 1994 and 2002 and who visited a urologist post-diagnosis were included. Pts who saw a MOH before the urologist visit were excluded. For pts who saw a MOH, time to a MOH visit was identified using the diagnosis date and the urologist visit as starting points. Survival models were used to examine the effect of the time (in months) to MOH visit on survival, controlling for demographic, clinical, continuity-of-care, and ecological measures. Results: There were 6,498 pts in the sample (mean age 76 years, 82% White race). PC-specific mortality was 38%. Two-thirds (67%) of patients did not visit a MOH after visiting a urologist. Among those with a visit to a MOH, an additional month from diagnosis till the MOH visit was positively associated with PC mortality (HR: 1.03; p < 0.001) - i.e. a shorter time to a MOH visit was associated with PC survival. Similar results were obtained using the month of the urologist visit as the starting point (HR: 1.02; p < 0.001). Conclusions: Among A-PC patients who are referred to an oncologist, each additional month between diagnosis/urologist visit and the oncologist visit is associated with an increased relative risk of mortality. [Table: see text]
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Affiliation(s)
- C. D. Mullins
- University of Maryland, Baltimore, MD; sanofi- aventis, Bridgewater, NJ
| | - E. Onukwugha
- University of Maryland, Baltimore, MD; sanofi- aventis, Bridgewater, NJ
| | - B. Seal
- University of Maryland, Baltimore, MD; sanofi- aventis, Bridgewater, NJ
| | - A. Hussain
- University of Maryland, Baltimore, MD; sanofi- aventis, Bridgewater, NJ
| | - A. Hussain
- University of Maryland, Baltimore, MD; sanofi- aventis, Bridgewater, NJ
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Camacho F, Mullins CD, Joish V, Choi J. Common head and neck cancer treatment pathways and associated costs in the U.S. commercial managed care population. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.e17001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17001 Background: For the treatment of head and neck cancer (HNC), different modalities (chemotherapy, radiation, surgery, or chemoradiotherapy) can be used either independently or in combination with others. Information regarding real-world treatment pattern is limited. The purpose of this study was to identify common treatment pathways and associated costs. Methods: The study was performed using data from a large U.S. commercial managed care claims database. Adult subjects (≥18) diagnosed with HNC between January 1, 2006, to December 31, 2006, (index-period) were identified based on a pre-selected ICD-9-CM codes. All subjects were HNC diagnosis-naïve 12 months prior to their index dates (first date of HNC diagnosis) and followed for 12 months post index date. Treatment modalities were identified based on the Healthcare Common Procedure Coding System used in the U.S. Pathways were constructed by reflecting time of and between modality administration claims. Results: 6,570 subjects were identified. The average age was 61 years (±14.9) and 44% (n = 2869) were female. Midwest (31%) and east (31%) region had a higher (p < 0.01) representation, compared to south (20%) and west (18%). Only 2,257 subjects (34%) received some type of treatment modality and were categorized into 20 mutually exclusive treatment pathways. Of these, 82% (n = 1,843) received single modality, 18% (n = 398) received a combination of 2, and 0.7% (n = 16) received a combination of 3 modalities. Among single modality pathways, radiation (34%; n = 619) was most common, however, cheomoradiotherapy (26%; n = 485) had the highest average patient cost ($98,440). Within double modalities, radiation followed by chemotherapy (24%; n = 95) was most common, however, chemoradiotherapy followed by surgery (4%; n = 16) had the highest average cost ($146,374). Within triple modalities, surgery followed by radiation then chemotherapy (50%; n = 8) was most common and costly ($95,868). Conclusions: The most common treatment pathways one year post HNC diagnosis used a single modality; however, the average patient costs within multiple modalities were higher. Further study is required to investigate if these patterns are comparable to current guideline recommendation. [Table: see text]
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Affiliation(s)
- F. Camacho
- Penn State University School of Medicine, Hershey, PA; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ; Rutgers University, Piscataway, NJ
| | - C. D. Mullins
- Penn State University School of Medicine, Hershey, PA; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ; Rutgers University, Piscataway, NJ
| | - V. Joish
- Penn State University School of Medicine, Hershey, PA; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ; Rutgers University, Piscataway, NJ
| | - J. Choi
- Penn State University School of Medicine, Hershey, PA; University of Maryland School of Pharmacy, Baltimore, MD; sanofi-aventis, Bridgewater, NJ; Rutgers University, Piscataway, NJ
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Choi JC, Chang JD, Seal B, Tangirala M, Mullins CD. Risk and cost of anthracycline-induced cardiotoxicity among breast cancer patients in the United States. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.1037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1037 Background: Onset of anthracycline-induced cardiotoxicity is well documented. However, information regarding the time of onset varies depending on literature. The purpose of this study was to compare the risk of cardiotoxicity among three cohort groups: anthracycline-containing-chemotherapy (ACC), no-anthracycline-containing-chemotherapy (NACC), and no-chemotherapy (control) groups. Methods: A retrospective cohort study was designed using commercial managed care claims database. Adult subjects (≥18) diagnosed with breast cancer, between January 1, 2002 to December 31, 2005, (index-period) were followed for 24 months. Subjects with a previous cardiotoxic events (CE), breast cancer diagnosis, or anthracycline-use 12-months prior to index date were excluded. Index date was the first chemotherapy claim date for ACC and NACC and non-chemotherapy medication claim date for controls. Cohorts were matched by index date and year of birth. CE was defined based on ICD-9-CM and Healthcare Common Procedure Coding System codes. Risk of CE was evaluated using a logistic model with and without adjusting for confounders. Results: 21,106 subjects were classified as ACC (n = 3,428), NACC (n = 7,125), and controls (n = 10,553). NACC cohort was significantly (p < 0.01) older (mean age: 62 years ±12.5) compared to ACC (53±9.7) or control cohorts (59±12.5). ACC cohort had a higher (p < 0.01) average degree of comorbidity, (1.8±0.8) compared to NACC (1.6±0.9) or control (1.3±0.8) as measured by Charlson comorbidity-index. Higher rates of CE were found within the ACC group compared to NACC and controls as early as month 3 post index-date and remained consistent over 24 months. At month 12 post index-date, 14% (n = 485) of ACC and 5% (n = 381) of NACC had CE compared to 3% (n = 310) of controls. After adjusting for all baseline differences, the odds ratio of CE compared to controls was 3.98 (95% CI: 3.27–4.85), and 1.31 (95% CI: 1.11–1.54) for ACC and NACC cohorts, respectively. The total mean costs were $59,287, $20,528, and $11,600, among ACC, NACC, and control cohorts respectively. Conclusions: Compared to NACC and controls, ACC cohorts had significantly higher risk of cardiotoxic events and seen as early as month 3 post treatment initiation. [Table: see text]
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Affiliation(s)
- J. C. Choi
- Rutgers University, Piscataway, NJ; Beth Israel Deaconess Medical Center, Boston, MA; sanofi-aventis, Bridgewater, NJ; Smith Hanley Consulting Group, Lake Mary, FL; University of Maryland School of Pharmacy, Baltimore, MD
| | - J. D. Chang
- Rutgers University, Piscataway, NJ; Beth Israel Deaconess Medical Center, Boston, MA; sanofi-aventis, Bridgewater, NJ; Smith Hanley Consulting Group, Lake Mary, FL; University of Maryland School of Pharmacy, Baltimore, MD
| | - B. Seal
- Rutgers University, Piscataway, NJ; Beth Israel Deaconess Medical Center, Boston, MA; sanofi-aventis, Bridgewater, NJ; Smith Hanley Consulting Group, Lake Mary, FL; University of Maryland School of Pharmacy, Baltimore, MD
| | - M. Tangirala
- Rutgers University, Piscataway, NJ; Beth Israel Deaconess Medical Center, Boston, MA; sanofi-aventis, Bridgewater, NJ; Smith Hanley Consulting Group, Lake Mary, FL; University of Maryland School of Pharmacy, Baltimore, MD
| | - C. D. Mullins
- Rutgers University, Piscataway, NJ; Beth Israel Deaconess Medical Center, Boston, MA; sanofi-aventis, Bridgewater, NJ; Smith Hanley Consulting Group, Lake Mary, FL; University of Maryland School of Pharmacy, Baltimore, MD
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Chung JH, Mullins CD, Manchanda V, Gunn ML, Stern EJ. Pulmonary artery intimal injury associated with blunt trauma. Emerg Radiol 2008; 16:497-9. [DOI: 10.1007/s10140-008-0783-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 11/14/2008] [Indexed: 10/21/2022]
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Zuckerman IH, Davidoff AJ, Onukwugha E, Pandya N, Gardner JF, Seal B, Obeidat N, Rapp T, Mullins CD, Choti MA. Effect of age on survival benefit of adjuvant chemotherapy in elderly stage III colon cancer patients: a population-based analysis. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.4014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Tang M, Davidoff AJ, Mullins CD, McNally D, Seal B, Edelman MJ. Chemotherapy (C) and survival among 21,441 elderly (E) patients (pts) with advanced (adv) NSCLC: Analysis of SEER-Medicare claim data 1997-2002. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.8090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mullins CD, Hsu VD, Onukwugha E, Zuckerman IH, Hussain A. Disparities and trends in prostate cancer staging over time. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.5160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Davidoff AJ, Choti MA, Zuckerman IH, Obeidat N, Rapp T, Onukwugha E, Sullivan P, Gardner JF, Mullins CD, Hanna NN. Is there evidence of diminishing disparities in treatment (tx) with adjuvant (adj) chemotherapy (Ch) among elderly (E) stage 3 colon cancer (CC) patients (pts)? An analysis of 8,374 pts from SEER-Medicare data. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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34
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Edelman MJ, Tang M, Gardner JF, Mullins CD, Seal B, Davidoff AJ. Therapy (Tx) of locally advanced (LA) NSCLC in the elderly: Analysis of 6,325 patients from Surveillance, Epidemiology and End Results (SEER)-Medicare. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.7549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Asche C, McAdam-Marx C, Seal B, Crookston B, Mullins CD. Treatment costs associated with community-acquired pneumonia by community level of antimicrobial resistance. J Antimicrob Chemother 2008; 61:1162-1168. [DOI: 10.1093/jac/dkn073] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Remák E, Mullins CD, Akobundu E, Charbonneau C, Woodruff K. Economic evaluations of sunitinib versus interferon-alfa (IFN-α) in first-line metastatic renal cell carcinoma (mRCC). J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6607 Background: A randomized phase III trial of sunitinib vs. IFN-a as first-line therapy for patients with mRCC is ongoing. An interim analysis of this study demonstrated superiority for the primary endpoint, progression-free survival (PFS), in the sunitinib arm vs. the IFN-a arm (median PFS = 11 months [95% CI: 10–12] vs. 4 months [95% CI: 4–6]; P<0.000001). Because of the clinical significance of these results, the objective of this study was to demonstrate the economic value of sunitinib vs. IFN-a in this setting from a US third-party payer perspective. Methods: Two Markov models with a 5- and 10-year time horizon were developed to evaluate the cost- effectiveness of sunitinib vs. IFN-a. The models projected survival and costs in 6-week cycles based on extrapolation of the trial survival data. Model 1 looked at first-line treatment followed by palliative care only, while Model 2 incorporated second-line treatment. Effectiveness was measured in terms of progression-free months (PFM) in Model 1, and life-years (LY) gained and quality adjusted life-years (QALY) gained in Model 2. Resource utilization included drugs, tests, scans, monitoring, physician visits, hospitalizations and treatment of adverse events. Costs and survival benefits were discounted annually at 3% and 5% in Model 1 and 2, respectively. All costs were adjusted to 2006 US dollars. Scenario and probabilistic sensitivity analyses were conducted. Results: Projected PFS and overall survival were longer for sunitinib than for IFN-a. The incremental cost-effectiveness ratios of sunitinib vs. IFN-a over 5- and 10-years were $7,769 and $7,782/PFM, respectively, in Model 1. Model 2 results at 10 years were $67,215/LY and $52,593/QALY gained. The key drivers of the model results were survival and sunitinib drug costs. Both models were robust in the tested scenarios. Conclusions: Both analyses found that sunitinib is a cost-effective alternative to IFN-a as first-line treatment in mRCC, with cost-effectiveness ratios within the established threshold that society is willing to pay for health benefits (i.e. $50,000–100,000/LY or QALY). No significant financial relationships to disclose.
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Affiliation(s)
- E. Remák
- United BioSource Corporation, London, United Kingdom; University of Maryland School of Pharmacy, Baltimore, MD; Pfizer Inc., New York, NY
| | - C. D. Mullins
- United BioSource Corporation, London, United Kingdom; University of Maryland School of Pharmacy, Baltimore, MD; Pfizer Inc., New York, NY
| | - E. Akobundu
- United BioSource Corporation, London, United Kingdom; University of Maryland School of Pharmacy, Baltimore, MD; Pfizer Inc., New York, NY
| | - C. Charbonneau
- United BioSource Corporation, London, United Kingdom; University of Maryland School of Pharmacy, Baltimore, MD; Pfizer Inc., New York, NY
| | - K. Woodruff
- United BioSource Corporation, London, United Kingdom; University of Maryland School of Pharmacy, Baltimore, MD; Pfizer Inc., New York, NY
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Pradel FG, Subedi P, Varghese AA, Mullins CD, Weis KA. Does earlier headache response equate to earlier return to functioning in patients suffering from migraine? Cephalalgia 2006; 26:428-35. [PMID: 16556244 DOI: 10.1111/j.1468-2982.2005.01043.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study explored the association between headache response and return to functioning, and identified migraine-associated symptoms related to functional status and acceptability of migraine treatment as reported by patients. Data from migraineurs enrolled in the active arms of a randomized, double-blind, parallel group, placebo-controlled, clinical trial were analysed. The relationships between headache response and functional response, and clinical factors and treatment acceptability were assessed using chi(2) tests of proportions and logistic regressions. A greater proportion of patients with headache response at 0.5 h were functioning at 0.5, 1 and 2 h compared with patients who did not attain a headache response at 0.5 h (P < 0.0001). These patients also were more likely to find their treatment acceptable (P < 0.05). The results suggest a direct temporal relationship among the key determinants of migraine resolution. Rapid headache response is associated with faster return to functioning; rapid headache and functional responses are significant attributes of treatment acceptability.
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Affiliation(s)
- F G Pradel
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD 21201, USA.
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Mullins CD. The economics of lipid management. Manag Care 2001; 10:17-8; discussion 19-24. [PMID: 11761626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- C D Mullins
- Dept. of Pharmacy Practice and Science, University of Maryland, USA
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Mullins CD. A welcome debate on statistical analysis. Clin Ther 2001; 23:1746. [PMID: 11726008 DOI: 10.1016/s0149-2918(01)80141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Perfetto EM, Mullins CD, Subedi P, Li-McLeod J. Selection of clinical, patient-reported, and economic end points in acute exacerbation of chronic bronchitis. Clin Ther 2001; 23:1747-72. [PMID: 11726009 DOI: 10.1016/s0149-2918(01)80142-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute exacerbation of chronic bronchitis (AECB) places tremendous burden on patients, providers, employers, and health care systems. OBJECTIVE The purpose of this paper is to (1) review the clinical, patient-reported, and economic measures used to evaluate disease burden and treatment effectiveness in AECB in clinical trials and (2) propose a guide for selecting study end points in AECB that will help capture all the relevant disease outcomes. METHODS Two literature searches of the PubMed database were conducted to identify studies of clinical trials in bronchitis and evaluate the clinical, patient-reported, and economic end points used in these studies. RESULTS Previous studies have focused primarily on clinician-assessed outcomes, which do not capture the full impact of AECB on patients' lives. Reporting mechanisms for most end points have been inconsistent, limiting the ability to compare information or interpret differences. Previous studies have given limited attention to patient-reported outcomes and the economic implications of AECB. Patient-reported outcomes such as speed of symptom relief and work productivity are important parameters for assessing treatment effectiveness and provide practical information for treatment evaluation. CONCLUSIONS Additional research is needed to develop, examine, and validate patient-reported outcomes and the indirect costs of AECB. Measuring the relevant clinical, economic, and patient-reported outcomes in AECB patients using standardized methods may lead to a clearer understanding of the disease burden and the role, effectiveness, and cost-effectiveness of antibiotic treatment.
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Affiliation(s)
- E M Perfetto
- Healthcentric Associates, Stevensville, Maryland, USA
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Affiliation(s)
- C D Mullins
- Center on Drugs and Public Policy, University of Maryland School of Pharmacy, Baltimore, USA
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Brooks SE, Ahn J, Mullins CD, Baquet CR, D'Andrea A. Health care cost and utilization project analysis of comorbid illness and complications for patients undergoing hysterectomy for endometrial carcinoma. Cancer 2001; 92:950-8. [PMID: 11550170 DOI: 10.1002/1097-0142(20010815)92:4<950::aid-cncr1405>3.0.co;2-o] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective was to study the association of race, comorbid illness, and lymph node dissection (LND) with complications in patients undergoing hysterectomy for endometrial carcinoma. METHODS The Health Care Cost Utilization Project analysis studied women undergoing hysterectomy for endometrial carcinoma in 1996. Chi-square and Student t tests were used to determine differences in means or proportions. Linear, stepwise, and three-stage regression analyses were used to build predictive models for charges and lengths of stay (LOS). RESULTS The mean age of the 5730 patients was 64.5 (standard deviation, 12.37); 72% of the patients were white, 5% were African American, and 23% were classified as "other." Ninety percent underwent total abdominal hysterectomy, 5% total vaginal hysterectomy (TVH), 4% radical abdominal hysterectomy, and 1% TVH/laparoscopy. Thirty-eight percent also underwent LND. Lymph node dissection was performed more frequently at teaching hospitals (P = 0.0000) and was associated with more complications. Comorbid illness (i.e., diabetes, heart disease) was documented in 51% of admissions, and > or = 1 comorbidity was documented in 21.5%. African Americans were more likely to have one or more comorbid illnesses, underwent more LNDs (P = 0.02), suffered more complications (P = 0.0001), and were more likely to die in the hospital compared with whites or others (P = 0.000). Although LND, complications, and longer LOS were more likely to occur in teaching hospitals (P = 0.0005), total charges and inpatient death were not higher in teaching hospitals. CONCLUSIONS The higher frequency of comorbid illness, complications, LND, and inpatient death in African Americans reflects severity of medical illness and cancer in these patients. Teaching hospital admission was associated with more complications and longer LOS, but not a higher death rate.
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Affiliation(s)
- S E Brooks
- Department of Obstetrics and Gynecology, School of Medicine, University of Maryland, 405 W. Redwood Street 3rd Floor, Baltimore, MD 21201, USA.
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Mullins CD. Subgroup analysis versus post-hoc analysis. Clin Ther 2001; 23:1060. [PMID: 11519770 DOI: 10.1016/s0149-2918(01)80091-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
BACKGROUND For individuals with emphysema because of severe alpha(1)-antitrypsin deficiency, specific therapy called IV augmentation therapy has been available since 1989. Such therapy consists of IV infusion of pooled human plasma alpha(1)-antiprotease. METHODS To assess the direct medical costs of having alpha(1)-antitrypsin deficiency, the current study surveyed members of the Alpha One Foundation Registry for Individuals With alpha(1)-Antitrypsin Deficiency regarding their annual expenditures for treatment of this disease. Data regarding demographic features, alpha(1)-antitrypsin status, and health-resource utilization were collected from a self-administered questionnaire. Respondents were asked to provide total health-care expenditures, but costs by specific items of care (eg, drugs, physician visits, etc) were not available. RESULTS Mean annual cost estimates were higher for PI*ZZ-phenotype individuals ($30,948, n = 292) than for non-PI*ZZ-phenotype individuals ($20,673, n = 53; p = 0.049). Among PI*ZZ-phenotype individuals, self-reported costs of health-care services were further analyzed for those 288 individuals whose alpha(1)-antiprotease use status was reported. For the 185 current alpha(1)-antiprotease users, the mean annual cost was $40,123 (median, $36,000). CONCLUSIONS Annual health-care expenditures by individuals with alpha(1)-antitrypsin deficiency are very high, whether or not they are currently receiving augmentation therapy. Augmentation therapy adds substantial costs, especially for heavier individuals who are receiving weekly infusions.
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Affiliation(s)
- C D Mullins
- University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
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Mullins CD. Borrowing from other disciplines. Clin Ther 2001; 23:480. [PMID: 11318081 DOI: 10.1016/s0149-2918(01)80051-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mullins CD. The new administration and Medicare reform. Clin Ther 2001; 23:126. [PMID: 11219472 DOI: 10.1016/s0149-2918(01)80035-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Few studies have estimated the indirect costs of care for HIV infection in England by stage of infection at a population level. OBJECTIVE This study estimated annual indirect costs of the HIV epidemic in England in 1997-1998 from both a public-sector and societal perspective. METHODS Service costs for HIV-infected individuals were indexed to 1997-1998 English prices. Average annual indirect costs included the costs of statutory, community, and informal services; disability payments; and lost economic productivity by stage of HIV infection. Disability payments were excluded from the societal perspective, whereas the degree of lost economic productivity was varied for the sensitivity analyses. Total average annual indirect costs by stage of HIV infection were calculated, as were population-based costs by stage of HIV infection and overall population costs. RESULTS Annual indirect costs from the public-sector and societal perspectives, respectively, ranged from pound sterling 3169 (dollars 5252) to pound sterling 3931 (dollars 6515) per person-year for asymptomatic individuals, pound sterling 5302 (dollars 8787) to pound sterling 7929 (dollars 13,140) for patients with symptomatic non-AIDS, and pound sterling 9956 (dollars 16,499) to pound sterling 21,014 (dollars 34,825) for patients with AIDS. Estimated population-based indirect costs from the public-sector perspective varied between pound sterling 109 million (dollars 181 million) and pound sterling 145 million (dollars 241 million) for 1997-1998, respectively, comprising between 58% and 124% of direct treatment costs for triple drug therapy in England during 1997. From the societal perspective, estimated population-based costs varied between pound sterling 84 million (dollars 138 million) and pound sterling 119 million (dollars 198 million) in 1997-1998, comprising between 45% and 102% of direct treatment costs and cost of care, respectively, during 1997. CONCLUSIONS Average indirect costs increase as HIV-infected individuals' illness progresses. Whether one takes a public-sector or societal perspective, indirect costs add a considerable amount to the cost of delivering health care to HIV-infected individuals. Both direct and indirect costs, when obtainable, should be used to assess the economic consequences of HIV infection and treatment interventions.
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Affiliation(s)
- C D Mullins
- University of Maryland School of Pharmacy, Baltimore 21201, USA.
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Brooks SE, Chen TT, Ghosh A, Mullins CD, Gardner JF, Baquet CR. Cervical cancer outcomes analysis: impact of age, race, and comorbid illness on hospitalizations for invasive carcinoma of the cervix. Gynecol Oncol 2000; 79:107-15. [PMID: 11006041 DOI: 10.1006/gyno.2000.5901] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the association of age, race, and comorbid illness with procedures and complications in hospitalized patients with invasive carcinoma of the cervix in a statewide population-based database over a 3-year period. METHODS Hospitalizations were classified into homogeneous subgroups based on a diagnosis of invasive cervical cancer. Cancer-related complications and comorbid diseases were evaluated. chi(2) and t tests determined differences in means or proportions. Linear regression techniques were applied to build models for hospitalization charges and lengths of stay (LOS). RESULTS There were 1009 admissions. The mean age was 49.5, with a median age of 46 (21-100, SD 15.4). Of the total, 606/1009 (60%) were white, 354/1009 (35%) were African-American (AA), and 5% were "other" races. AAs were more likely to have Medicaid or be uninsured (44% vs 23%, P = 0. 001) and were more likely to be admitted for an emergency (unadjusted odds ratio (OR) = 1.6; 1.2-2.2), to have a comorbid illness (P = 0.001), to be admitted for a cancer-related complication (P = 0.036), to be admitted for a transfusion (P = 0. 01), and to be admitted for radiation therapy rather than surgery (P = 0.001). The following were associated with LOS and higher hospital costs: emergency admissions for complications of cancer, comorbid illness, and older age. CONCLUSIONS Racial differences exist in patterns of admission, type of therapy, and severity of illness; however, there were no differences in charges or LOS for similar procedures. The large percentage of African-Americans uninsured or insured by government-supported programs indicates the potential impact of public policy on the care of these patients. Socioeconomic status rather than phenotypic appearance may be a more important determinant of outcome.
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Affiliation(s)
- S E Brooks
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Maryland, Baltimore, Maryland 21201, USA.
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Abstract
OBJECTIVE To estimate the cost per ischaemic event (death, nonfatal myocardial infarction, subsequent revascularisation procedure) avoided at 6 months in high risk patients undergoing coronary revascularisation treated with abciximab during routine medical care. DESIGN Retrospective, matched cohort design. SETTING University teaching hospital. PATIENTS 62 abciximab-treated patients and 62 patients not treated with abciximab with high risk coronary lesions were matched according to gender, hyperlipidaemia, diabetes mellitus and stenting. MAIN OUTCOME MEASURES Using a third-party payer's perspective, an incremental cost-effectiveness ratio (ICER) was computed as the cost per ischaemic event avoided over 6 months. Fieller's theorem was used to estimate confidence sets and confidence ellipses were generated to visually represent the variability in the data. RESULTS At 6 months, abciximab-treated patients experienced an approximately 40% lower rate of ischaemic events (16.1 vs 27.4%; p = 0.128). The point estimate of the ICER was $US21,789 per ischaemic event avoided. Fieller's theorem resulted in a 95% confidence set consisting of 2 half-lines (-infinity to -$US115,461) and ($US391 to +infinity), reflecting the finding that the ICER denominator was not significantly different from zero at the p = 0.05 level. CONCLUSIONS In high risk patients treated during routine care, the effectiveness of abciximab was consistent with efficacy rates from clinical trials. However, abciximab-treated patients remained approximately $US2400 more costly at 6 months.
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Affiliation(s)
- S O Reed
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA.
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