Financial Insolvency as a Risk Factor for Early Mortality Among Patients With Cancer

PURPOSE

Patients with cancer are more likely to file for bankruptcy than the general population, but the impact of severe financial distress on health outcomes among patients with cancer is not known.

METHODS

We linked Western Washington SEER Cancer Registry records with federal bankruptcy records for the region. By using propensity score matching to account for differences in several demographic and clinical factors between patients who did and did not file for bankruptcy, we then fit Cox proportional hazards models to examine the relationship between bankruptcy filing and survival.

RESULTS

Between 1995 and 2009, 231,596 persons were diagnosed with cancer. Patients who filed for bankruptcy (n = 4,728) were more likely to be younger, female, and nonwhite, to have local- or regional- (v distant-) stage disease at diagnosis, and have received treatment. After propensity score matching, 3,841 patients remained in each group (bankruptcy v no bankruptcy). In the matched sample, mean age was 53.0 years, 54% were men, mean income was $49,000, and majorities were white (86%), married (60%), and urban (91%) and had local- or regional-stage disease at diagnosis (84%). Both groups received similar initial treatments. The adjusted hazard ratio for mortality among patients with cancer who filed for bankruptcy versus those who did not was 1.79 (95% CI, 1.64 to 1.96). Hazard ratios varied by cancer type: colorectal, prostate, and thyroid cancers had the highest hazard ratios. Excluding patients with distant-stage disease from the models did not have an effect on results.

CONCLUSION

Severe financial distress requiring bankruptcy protection after cancer diagnosis appears to be a risk factor for mortality. Further research is needed to understand the process by which extreme financial distress influences survival after cancer diagnosis and to find strategies that could mitigate this risk.

Referral and treatment patterns among patients with stages III and IV non-small-cell lung cancer

PURPOSE

Little is known about how referrals to different cancer specialists influence cancer care for non-small-cell lung cancer (NSCLC). Among Medicare enrollees, we identified factors of patients and their primary care physician that were associated with referrals to cancer specialists, and how the types of cancer specialists seen correlated with delivery of guideline-based therapies (GBTs).

METHODS

Data from patients with stages III and IV NSCLC included in the SEER-Medicare database were linked to their physicians in the American Medical Association Masterfile database. Using logistic regression, we (1) identified patient and physician factors that were associated with referrals to cancer specialists (medical oncologists, radiation oncologists, and surgeons); (2) identified the types of referral to cancer specialists that predicted greater likelihood of receiving GBT (per National Comprehensive Cancer Network guidelines).

RESULTS

A total of 28,977 patients with NSCLC diagnosed from January 1, 2000 to December 31, 2005 met eligibility criteria. Younger age, white race, higher income, and primary physician specialty other than family practice predicted higher likelihood of referrals to medical oncologists (P < .01 for all predictors). Seeing the three types of cancer specialists predicted higher likelihood of GBT (stage IIIA: odds ratio [OR] = 20.6; P < .001; IIIB: OR = 77.2; P < .001; and IV: OR = 1.2; P = .011), compared with seeing a medical oncologist only. Use of GBTs increased over the study period (42% to 48% from 2000 to 2005; P < .001).

CONCLUSION

Referrals to all types of cancer specialists increased the likelihood of treatment with standard therapies, particularly in stage III patients. However, racial and income disparities still prevent optimal referrals to cancer specialists.

Impact of prostate cancer on sexual relationships: a longitudinal perspective on intimate partners' experiences

INTRODUCTION

In this prospective study of localized prostate cancer patients and their partners, we analyzed how partner issues evolve over time, focusing on satisfaction with care, influence of cancer treatment, and its impact on relationship with patient, cancer worry, and personal activities.

AIMS

Our study aims were twofold: (i) to determine whether the impact of treatment on patients and partners moderate over time and (ii) if receiving surgery (i.e., radical prostatectomy) influences partner issues more than other treatments.

METHODS

Patients newly diagnosed with localized prostate cancer and their female partners were recruited from three states to complete surveys by mail at three time points over 12 months.

MAIN OUTCOME MEASURES

The four primary outcomes assessed in the partner analysis included satisfaction with treatment, cancer worry, and the influence of cancer and its treatment on their relationship (both general relationship and sexual relationship).

RESULTS

This analysis included 88 patient-partner pairs. At 6 months, partners reported that cancer had a negative impact on their sexual relationship (39%--somewhat negative and 12%--very negative). At 12 months, this proportion increased substantially (42%--somewhat negative and 29%--very negative). Partners were significantly more likely to report that their sexual relationship was worse when the patient reported having surgery (P = 0.0045, odds ratio = 9.8025, 95% confidence interval 2.076-46.296). A minority of partners reported significant negative impacts in other areas involving their personal activities (16% at 6 months and 25% at 12 months) or work life (6% at 6 months, which increased to 12% at 12 months).

CONCLUSION

From partners' perspectives, prostate cancer therapy has negative impact on sexual relationships and appears to worsen over time.

Is a comparative clinical trial for breast cancer tumor markers to monitor disease recurrence warranted? A value of information analysis

BACKGROUND

Breast cancer tumor markers are used by some clinicians to screen for disease recurrence risk. Since there is limited evidence of benefit, additional research may be warranted.

AIM

To assess the potential value of a randomized clinical trial of breast tumor marker testing in routine follow-up of high-risk, stage II-III breast cancer survivors.

MATERIALS & METHODS

We developed a decision-analytic model of tumor marker testing plus standard surveillance every 3-6 months for 5 years. The expected value of sample information was calculated using probabilistic simulations and was a function of: the probability of selecting the optimal monitoring strategy with current versus future information; the impact of choosing the nonoptimal strategy; and the size of the population affected.

RESULTS

The value of information for a randomized clinical trial involving 9000 women was US$214 million compared with a cost of US$30-60 million to conduct such a trial. The probability of making an alternate, nonoptimal decision and choosing testing versus no testing was 32% with current versus future information from the trial. The impact of a nonoptimal decision was US$2150 and size of population impacted over 10 years was 308,000. The value of improved information on overall survival was US$105 million, quality of life US$37 million and test performance US$71 million.

CONCLUSION

Conducting a randomized clinical trial of breast cancer tumor markers appears to offer a good societal return on investment. Retrospective analyses to assess test performance and evaluation of patient quality of life using tumor markers may also offer valuable areas of research. However, alternative investments may offer even better returns in investments and, as such, the trial concept deserves further study as part of an overall research-portfolio evaluation.

Variation in prescribing patterns and therapeutic drug monitoring of intravenous busulfan in pediatric hematopoietic cell transplant recipients

Personalizing intravenous (IV) busulfan doses in children using therapeutic drug monitoring (TDM) is an integral component of hematopoietic cell transplant. The authors sought to characterize initial dosing and TDM of IV busulfan, along with factors associated with busulfan clearance, in 729 children who underwent busulfan TDM from December 2005 to December 2008. The initial IV busulfan dose in children weighing ≤12 kg ranged 4.8-fold, with only 19% prescribed the package insert dose of 1.1 mg/kg. In those children weighing >12 kg, the initial dose ranged 5.4-fold, and 79% were prescribed the package insert dose. The initial busulfan dose achieved the target exposure in only 24.3% of children. A wide range of busulfan exposures were targeted for children with the same disease (eg, 39 target busulfan exposures for the 264 children diagnosed with acute myeloid leukemia). Considerable heterogeneity exists regarding when TDM is conducted and the number of pharmacokinetic samples obtained. Busulfan clearance varied by age and dosing frequency but not by underlying disease. The authors- group is currently evaluating how using population pharmacokinetics to optimize initial busulfan dose and TDM (eg, limited sampling schedule in conjunction with maximum a posteriori Bayesian estimation) may affect clinical outcomes in children.

Predicting costs of care in heart failure patients

BACKGROUND

Identifying heart failure patients most likely to suffer poor outcomes is an essential part of delivering interventions to those most likely to benefit. We sought a comprehensive account of heart failure events and their cumulative economic burden by examining patient characteristics that predict increased cost or poor outcomes.

METHODS

We collected electronic medical data from members of a large HMO who had a heart failure diagnosis and an echocardiogram from 1999-2004, and followed them for one year. We examined the role of demographics, clinical and laboratory findings, comorbid disease and whether the heart failure was incident, as well as mortality. We used regression methods appropriate for censored cost data.

RESULTS

Of the 4,696 patients, 8% were incident. Several diseases were associated with significantly higher and economically relevant cost changes, including atrial fibrillation (15% higher), coronary artery disease (14% higher), chronic lung disease (29% higher), depression (36% higher), diabetes (38% higher) and hyperlipidemia (21% higher). Some factors were associated with costs in a counterintuitive fashion (i.e. lower costs in the presence of the factor) including age, ejection fraction and anemia. But anemia and ejection fraction were also associated with a higher death rate.

CONCLUSIONS

Close control of factors that are independently associated with higher cost or poor outcomes may be important for disease management. Analysis of costs in a disease like heart failure that has a high death rate underscores the need for economic methods to consider how mortality should best be considered in costing studies.

A comparison of approaches for association studies of polymorphisms and colorectal cancer risk

AIM

Meta-analyses have been used to evaluate associations between polymorphisms and colorectal cancer risk, but the quality of individual studies used to inform them may vary substantially. Our aim was to apply well-established quality-control criteria to individual association studies and then compare the results of meta-analyses that included or excluded studies that did not meet these criteria.

METHOD

We used meta-analyses of studies reporting a relationship between polymorphisms and colorectal cancer published between 1996 and 2008. Polymorphism-cancer associations were derived in separate meta-analyses including only those meeting the quality-control criteria.

RESULTS

Relative ORs varied substantially between the open and restricted group meta-analyses for all variants except MTHFR 677 CT. However, the associations were modest and the direction of relative risk did not change after applying criteria. Publication bias was detected for all associations, except the restricted set of studies for GSTP1 GG.

CONCLUSION

We observed variation in calculated relative risk and changes in tests for publication bias that were dependent on the inclusion criteria used for association studies of polymorphisms and colorectal cancer. Standardizing study inclusion criteria may reduce the variation in findings for meta-analyses of gene-association studies of common diseases such as colorectal cancer.

Evaluating the impact of a trial in breast cancer tumor markers: A value of research analysis

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Background: Despite not being recommended by clinical guidelines, the tumor markers carcinoembryonic antigen (CEA), cancer antigen (CA)15-3, and CA 27.29 are used by some clinicians to screen for increased risk of breast cancer recurrence. Although additional research may be warranted to evaluate the benefits and risks of breast cancer tumor marker tests, clinical trials would likely need to involve thousands of women and would take many years to complete. We conducted an analysis to assess the societal value of a prospective randomized clinical trial (RCT) for breast tumor marker testing in routine follow-up of high-risk, stage II-III breast cancer survivors Methods: We used value of information techniques to assess the benefits of reducing uncertainty of using breast cancer tumor markers. We developed a decision-analytic model of biomarker testing in addition to standard surveillance at follow-up appointments every 3-6 months for five years. Expected value of sample information (EVSI) was assessed over a range of trial sizes and assumptions. Results: The overall value of research for an RCT involving 9,000 women was $166 million (EVSI). The value of improved information characterizing the survival impact of tumor markers was $81 million, quality-of-life $38 million, and test performance $95 million. Conclusions: Our analysis indicates that substantial societal value may be gained by conducting a clinical trial evaluating the use of breast cancer tumor markers. The most important aspects of the trial in our analysis were information gained on survival improvements as well as quality-of-life parameters associated with testing and test sensitivity and specificity. Our analysis indicates that smaller randomized trials, as well as adding quality of life instruments to existing trials, retrospective, and observational trials can also generate valuable and relevant information.

Who gets a referral to oncologists and subsequent treatments for stages III and IV non-small cell lung cancer (NSCLC)?

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Background: We identified the physicians initially involved in the management of stages III and IV NSCLC, and explored associations of patient and their initial physician factors with referrals to oncologists and subsequent receipt of guideline-based therapies (GBTs) endorsed by the National Comprehensive Cancer Network. Methods: Using a retrospective cohort design, we identified patients with a new diagnosis of stages III and IV NSCLC from 01/01/2000 to 12/31/2005 included in the Surveillance, Epidemiology, and End Results-Medicare database. After collecting patient sociodemographic, tumor, and treatment data, we linked Unique Physician Identifier Numbers (UPINs) from Medicare claims to the American Medical Association Masterfile database to identify the initial physicians and subsequent referrals to cancer specialists, defined as surgeons, radiation oncologists and oncologists. We used logistic regression to explore associations between: 1) patient and initial physician independent variables with referrals to oncologists; 2) referrals to different combinations of cancer specialists with receipt of stage-specific GBTs, adjusted for confounders. The follow-up period was 12 months or up to 12/31/2006. Results: For 28,977 patients, mean age was 75 years, 53% were male, 83% were white, 51% had stage IV, 37% initially saw an internal medicine doctor, 84% saw at least an oncologist, 31% saw all 3 types of cancer specialists, and 44% received GBTs. Younger age, white race, stage IV, higher income, lower co-morbidity index, initial physicians other than family practice doctors, and referral to pulmonologists were associated with higher likelihood of referral to oncologists (P<0.01 for all factors). Compared to those who saw only an oncologist, those who saw only a surgeon and/or a radiation specialist were less likely to receive GBTs (OR=0.3; 95%CI=0.3-0.4). Among patients who had no referrals or who saw specialties other than oncology, 14% received GBTs. Conclusions: Seeing an oncologist is a critical step in the standard treatment of advanced NSCLC. Yet, race, income, and the type of initial physician may constitute barriers of access to oncologists, which can result in substandard care.

Adverse events (AE) following diagnosis (Dx) in older metastatic colorectal cancer (mCRC) patients (Pts)

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Background: The relative safety of newer drugs in older pts with mCRC is understudied. The objective of this analysis is to determine factors associated with AEs in a population-based sample of older mCRC pts treated in real-world clinical settings. Methods: Pts ≥ age 65 Dx with mCRC in 2004-2007 were identified from SEER-Medicare, and excluded if they were enrolled in a Medicare HMO or lacked Medicare parts A and B. Pts who received 1st line (1L) chemotherapy (CTx) within 3 mo of Dx were dichotomized as 1L CTx alone and 1L CTx + bevacizumab (BV). Preexisting conditions (PCs) identified from claims in the 12 mo prior to start of 1L CTx were grouped into 5 categories (cardiovascular (CV), cerebrovascular (CNS), gastrointestinal (GI), tissue integrity (TI), and pulmonary (Pulm)). Claims for any of these same conditions between start of 1L CTx and end of follow-up were identified as AEs. Crude AE incidence rates were determined. Logistic regression was used to examine factors associated with BV use. Factors associated with time to 1st AE were identified in a Cox model. Results: 4,514 pts (median age 77) met inclusion, of whom 1,139 (25%) received 1L CTx only and 669 (15%) received 1L CTx + BV. BV use was less likely among pts age ≥ 75 (OR 0.35, p<0.001), non-whites (OR 0.75, p=0.002), and women (OR 0.8, p=0.001). Bev use was as likely in pts with CV, Pulm, or CNS PCs, and more likely in pts with GI (OR 1.67, p <0.001) and TI (OR 2.75, p=0.001) PCs. In a Cox model of time to 1st AE with death as a competing risk, increased risk of AE was associated with age ≥ 75 (HR 1.13, p=0.02), CNS PC (HR 1.35, p=0.02), and CV PC (HR 1.13, p=0.05). Relative to 1L CTx alone, pts receiving 1L CTx + BV did not have a higher AE risk (HR 0.89, 95% CI 0.80-0.99). AE incidence was higher in pts receiving 1L CTx alone (without subsequent biologic) (185 events / 100,000 person-days (P-D) compared with pts receiving 1L CTx + BV (139 events / 100,000 P-D). Conclusions: In this cohort, pts who received 1L CTx + BV had neither increased AE incidence nor increased risk of 1st AE compared to pts who received 1L CTx alone. PCs were not associated with decreased BV use. These data suggests BV utilization may not increase AE risk among elderly mCRC pts tx in the community.

A network meta-analysis of therapies for previously untreated chronic lymphocytic leukemia

BACKGROUND

Several therapy options are available for symptomatic, treatment-naïve chronic lymphocytic leukemia (CLL). Many of these therapies have been compared against chlorambucil, but have not been directly compared against each other. There is currently no agreed upon standard therapeutic regimen for treatment-naïve CLL.

METHODS

We performed a systematic literature review to identify randomized controlled trials (RCTs) published prior to November 2011 of therapies for previously untreated CLL. We conducted a network meta-analysis using fixed and random effect statistical models to estimate differences between shape and scale parameters of progression-free survival (PFS) curves for each competing therapy. We used the parameter estimates and a Weibull distribution to project mean PFS for each therapy option.

RESULTS

Five RCTs were included in our comparison network. Overall, patients were younger (59-65 years), had good performance status based on the Eastern Cooperative Oncology Group scale (ECOG 0-1), and earlier stage disease (Rai 0-II or Binet A or B). The combination regimen fludarabine with cyclophosphamide and rituximab (FCR) was estimated to yield mean PFS of 76 months (95% CrI: 60, 91), FC 60 months (46, 73), fludarabine 38 months (27, 49), alemtuzumab 24 months (15, 32), and chlorambucil 23 months (15, 32).

CONCLUSION

Our results suggest that FCR has relatively higher potential of preventing disease progression in younger, healthier, treatment-naïve CLL patients and should be considered an optimal initial treatment strategy for this patient population. However, because estimates are based on model simulation, additional studies of FCR are necessary to clinically validate its therapeutic potential.

Health insurer policies toward risk-stratified colorectal cancer screening: a survey of health plan medical directors

OBJECTIVES

We sought to determine whether health insurance coverage of colorectal cancer (CRC) screening varied based on risk.

BACKGROUND

Population-wide screening guidelines for cancer often incorporate risk information, with modified screening recommendations for those at higher risk due to family history or other factors.

METHODS

In a nationwide Internet- and mail-based survey of health insurance plan medical directors, respondents were asked about their organization's policies towards coverage of CRC screening for persons at average and higher risk of CRC. Additional questions asked about whether the insurer had a definition of increased risk, and coverage of genetic testing for familial CRC syndromes.

RESULTS

Survey invitations were sent to 1158 medical directors; 133 (11%) completed the survey. All plans covered screening for average and high-risk persons. The onset of screening was earlier and intervals were more frequent for higher risk compared to average risk persons, with most respondents stating coverage was determined by "physician discretion." While 75% had a definition of high risk, only 55% covered genetic testing.

CONCLUSIONS

Most insurers offer enhanced coverage of CRC screening, most commonly following the discretion of the physician. Whether this coverage results in earlier, more frequent, or more complete screening of higher risk persons remains uncertain.

Patterns of blood product use among patients with myelodysplastic syndrome

BACKGROUND AND OBJECTIVES

Most patients with myelodysplastic syndrome (MDS) require blood product support to manage the severe anaemias, which frequently accompany MDS. Our objective was to show the feasibility of linking the Surveillance, Epidemiology and End Results (SEER) database with records from Puget Sound Blood Center (PSBC) to characterize blood product use over time in successive cohorts of patients with MDS.

MATERIALS AND METHODS

We identified patients with MDS in the SEER registry. The cohort was then linked to PSBC records to discern blood product use.

RESULTS

Included in the analysis were 783 patients with MDS entered in the SEER database from 2001 to 2007 for whom data were also available in the PSBC database. Among patients with MDS who received transfusions, 97% received packed red blood cells; 52% received platelets. The proportion of patients with MDS receiving blood products declined from 2001 to 2007.

CONCLUSION

These data show a recent decline in blood product use for patients with MDS. Future studies are needed to further evaluate the reasons for this finding, specifically exploring the impact of newer medications on blood product use in patients with MDS.

Provider and partner interactions in the treatment decision-making process for newly diagnosed localized prostate cancer

OBJECTIVE

• To evaluate the degree to which the partners of prostate cancer patients participate in the shared decision-making process with the patients' providers during the time between diagnosis and initiating treatment.

PATIENTS AND METHODS

• We recruited patients with newly diagnosed local-stage prostate cancer and their partners to complete take-home surveys after biopsy but before initiating treatment at urology practices in three states. • We asked partners to describe their roles in the decision-making process, including participation in clinic visits, and perceptions of encouragement from providers to participate in the treatment decision-making process. We also asked partners to rate their satisfaction with the patients' providers.

RESULTS

• Family members of 80% of newly diagnosed patients agreed to participate; most (93%) were partners (i.e. spouses or significant others). Most partners (93%) had direct contact with the patients' physicians. • Among the partners who had contact with providers, most (67%) were very satisfied with the patients' providers and 80% indicated that the doctor encouraged them to participate in the treatment decision. Overall, 91% of partners reported very frequent discussions with their loved one about the pending treatment decision, and 69% reported that their role was to help the patient make a decision. • In multivariate models, provider encouragement of partner participation was associated with higher partner satisfaction (odds ratio 3.4, 95% CI 1.4-8.4) and an increased likelihood of partners reporting very frequent discussions with their loved one (odds ratio 6.1, 95% CI 1.3-27.7).

CONCLUSIONS

• Partners often attended clinic visits and were very involved in discussions about treatment options with both loved ones and providers. • Provider encouragement of participation by partners greatly facilitates shared decision-making between patients and partners.

Is distance to provider a barrier to care for medicaid patients with breast, colorectal, or lung cancer?

PURPOSE

Distance to provider might be an important barrier to timely diagnosis and treatment for cancer patients who qualify for Medicaid coverage. Whether driving time or driving distance is a better indicator of travel burden is also of interest.

METHODS

Driving distances and times from patient residence to primary care provider were calculated for 3,917 breast, colorectal (CRC) and lung cancer Medicaid patients in Washington State from 1997 to 2003 using MapQuest.com. We fitted regression models of stage at diagnosis and time-to-treatment (number of days between diagnosis and surgery) to test the hypothesis that travel burden is associated with timely diagnosis and treatment of cancer.

FINDINGS

Later stage at diagnosis for breast cancer Medicaid patients is associated with travel burden (OR = 1.488 per 100 driving miles, P= .037 and OR = 1.270 per driving hour, P= .016). Time-to-treatment after diagnosis of CRC is also associated with travel burden (14.57 days per 100 driving miles, P= .002 and 5.86 days per driving hour, P= .018).

CONCLUSIONS

Although travel burden is associated with timely diagnosis and treatment for some types of cancer, we did not find evidence that driving time was, in general, better at predicting timeliness of cancer diagnosis and treatment than driving distance. More intensive efforts at early detection of breast cancer and early treatment of CRC for Medicaid patients who live in remote areas may be needed.

Health care use and primary prophylaxis with colony-stimulating factors

OBJECTIVES

We examined health care use in conjunction with primary prophylaxis use of colony stimulating factors (CSF) during patients' initial course of chemotherapy.

METHODS

This retrospective cohort study identified adults aged 25 years and older with a diagnosis of breast, colorectal, or nonsmall cell lung cancer between 2002 and 2005 from the Western Washington Surveillance Epidemiology and End Results Puget Sound registry. We linked these records to health insurance claims from four payers representing 75% of those insured in the state. Claims records were used to determine chemotherapy regimen type, CSF use, febrile neutropenia occurrences, and supportive care. Chemotherapy regimens were categorized as conferring high, intermediate, or low risk of myelosuppression according to the National Comprehensive Cancer Network guidelines. CSF use was described as primary prophylaxis, other, or none. Antibiotics and antifungal and antiviral agents per National Comprehensive Cancer Network guidelines for supportive care for cancer infection were categorized using Healthcare Common Procedure Coding System and National Drug Code assignments.

RESULTS

Use of CSF as primary prophylaxis is not significantly associated with a reduction in antibiotic use or inpatient or outpatient visits. Primary prophylactic CSF use was associated with less use of antiviral drugs.

CONCLUSIONS

CSF use is not associated with a reduction in health care use, with the exception of antiviral drug use. Given the expense associated with CSF use, pragmatic trials and additional research are needed to further assess the affects of CSF on health care use.

Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery

BACKGROUND

Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.

OBJECTIVE

To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications.

DESIGN

This is a cohort study.

SETTING AND PARTICIPANTS

Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.

MAIN OUTCOME MEASURE

One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.

RESULTS

Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10.

CONCLUSIONS

AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

Provider and partner interactions in the treatment decision-making process for newly diagnosed localized prostate cancer

OBJECTIVE

• To evaluate the degree to which the partners of prostate cancer patients participate in the shared decision-making process with the patients' providers during the time between diagnosis and initiating treatment.

PATIENTS AND METHODS

• We recruited patients with newly diagnosed local-stage prostate cancer and their partners to complete take-home surveys after biopsy but before initiating treatment at urology practices in three states. • We asked partners to describe their roles in the decision-making process, including participation in clinic visits, and perceptions of encouragement from providers to participate in the treatment decision-making process. We also asked partners to rate their satisfaction with the patients' providers.

RESULTS

• Family members of 80% of newly diagnosed patients agreed to participate; most (93%) were partners (i.e. spouses or significant others). Most partners (93%) had direct contact with the patients' physicians. • Among the partners who had contact with providers, most (67%) were very satisfied with the patients' providers and 80% indicated that the doctor encouraged them to participate in the treatment decision. Overall, 91% of partners reported very frequent discussions with their loved one about the pending treatment decision, and 69% reported that their role was to help the patient make a decision. • In multivariate models, provider encouragement of partner participation was associated with higher partner satisfaction (odds ratio 3.4, 95% CI 1.4-8.4) and an increased likelihood of partners reporting very frequent discussions with their loved one (odds ratio 6.1, 95% CI 1.3-27.7).

CONCLUSIONS

• Partners often attended clinic visits and were very involved in discussions about treatment options with both loved ones and providers. • Provider encouragement of participation by partners greatly facilitates shared decision-making between patients and partners.

Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts.

Pharmacogenetics of intravenous and oral busulfan in hematopoietic cell transplant recipients

Kinetics-based dose targeting is often conducted in hematopoietic cell transplant (HCT) patients conditioned with intravenous (IV) or oral busulfan to lower rates of rejection, nonrelapse mortality, and relapse. Using the candidate gene approach, the authors evaluated whether busulfan clearance was associated with polymorphisms in the genes regulating the predominant metabolizing enzymes involved in busulfan conjugation, specifically glutathione S-transferase (GST) isoenzymes A1 (GSTA1) and M1 (GSTM1). Busulfan clearance was estimated after the morning dose on days 1, 2, and 3; each patient's average clearance was used for analyses. The average (± standard deviation) busulfan clearance was 3.2 ± 0.56 mL/min/kg in the separate population of 95 patients who received oral busulfan and 103 ± 24 ml/min/m(2) in the 57 patients who received IV busulfan. Oral busulfan clearance was associated with GSTA1 (P = .008) but not GSTM1 (P = .57) genotypes. However, among the GSTA1 haplotypes (ie, *A*A, *A*B, *B*B), there was significant overlap in the observed oral busulfan clearance and similar rates of achieving the target busulfan exposure. Clearance of IV busulfan was not associated with GSTA1 (P = .21) or GSTM1 (P = .99). These data suggest that personalizing either IV or oral busulfan dosing cannot be simplified on the basis of GSTA1 or GSTM1 genotype.

Lung cancer histology, stage, treatment, and survival in American Indians and Alaska Natives and whites

BACKGROUND

Studies of lung cancer disparities between American Indians and Alaska Natives (AIANs) and whites have yielded mixed results. To the authors' knowledge, no studies to date have investigated whether race-based differences in histology could explain survival disparities.

METHODS

Data were obtained on AIANs and whites with lung cancer from the 17 population-based cancer registries participating in the Surveillance, Epidemiology, and End Results (SEER) program from 1973 to 2006. Logistic regression was used to determine whether race and other covariates were associated with histology, stage at diagnosis, and receipt of surgery. Cox regression was used to determine the risk of death associated with race, after adjusting for histology, stage, and other covariates.

RESULTS

Histology, but not race, was found to be associated with stage at diagnosis, and both race and stage were found to be associated with histology. AIANs were less likely to receive surgery than whites, after adjusting for patient and tumor characteristics. Survival improved for both AIANs and whites after 2000, compared with the 1973 through 1999 period, but survival was consistently shorter for AIANs. The association between AIAN race and decreased survival was strongest in the later time period.

CONCLUSIONS

Lung cancer histology appears to be associated with tumor characteristics, treatment, and survival. AIAN race is associated with tumor histology, receipt of surgery, and survival. In the future, studies with access to smoking data, patient comorbidity information, and health systems-level data will be able to identify factors responsible for the disparities observed in these analyses.

Colony-stimulating factor prescribing patterns in patients receiving chemotherapy for cancer

OBJECTIVE

To examine variables influencing colony-stimulating factor (CSF) prescription as primary prophylaxis versus other use during patients' initial chemotherapy course among a large sample of health insurance records.

STUDY DESIGN

Retrospective cohort study.

METHODS

Adults 25 years or older with a diagnosis of breast, colorectal, or non-small cell lung cancer (NSCLC) between January 1, 2002, and December 31, 2005, were identified from the western Washington State Surveillance, Epidemiology, and End Results Seattle Puget Sound registry. We linked these records to health insurance claims. Chemotherapy regimens identified from insurance claims were categorized as carrying high, intermediate, or low risk of myelosuppression according to the National Comprehensive Cancer Network guidelines and the literature. Colony-stimulating factor use was described as primary prophylaxis, other use, or no use, and logistic regression analysis identified factors associated with CSF use.

RESULTS

For patients with breast cancer, colorectal cancer, and NSCLC, respectively, 58%, 0%, and 28% received CSFs as primary prophylaxis in conjunction with high-risk chemotherapy regimens, whereas 10%, 7%, and 21% did so in conjunction with low-risk chemotherapy regimens. Prophylactic CSF use increased from 2002 to 2005 for breast cancer but remained constant for colorectal cancer and for NSCLC.

CONCLUSIONS

As primary prophylaxis, CSF use is underutilized based on recommendations for patients having cancer who receive chemotherapy regimens carrying high febrile neutropenia risk and may be overutilized for patients who receive chemotherapy regimens carrying low febrile neutropenia risk. Further research is needed to understand the barriers to implementing guidelines in clinical practice.

Preliminary treatment considerations among men with newly diagnosed prostate cancer

OBJECTIVE

To assess factors that may influence men's preference for surgery versus nonsurgical options among newly diagnosed patients considering treatments for local-stage prostate cancer.

STUDY DESIGN

Prostate cancer patients were approached at urology clinics after diagnosis but prior to starting treatment in California, South Carolina, and Texas. Using a survey about the treatment decision-making process, patients were asked about their likes and dislikes of 5 common treatment options: surgery (prostatectomy), brachytherapy, external beam radiation therapy, hormone therapy, and watchful waiting.

METHODS

Logistic regression identified associations between treatment characteristics and choice of prostatectomy compared with nonsurgical options, controlling for demographic, clinical, and psychological covariates.

RESULTS

Of the 198 eligible men who returned the baseline survey, 59% indicated they only considered surgery and 41% considered at least 1 nonsurgical option. In multivariate analysis, patients who thought treatment efficacy was a primary concern were significantly more likely to prefer surgery only (odds ratio [OR] = 6.20, 95% confidence interval [95% CI] = 1.74, 22.10); those indicating concern about personal burden were significantly more likely to prefer nonsurgical options (OR = 0.07, 95% CI = 0.02, 0.22). Advice of friends and relatives and concerns over side effects were not significantly associated with preference for surgery versus other treatments.

CONCLUSIONS

Men's perceptions about treatment efficacy and the personal burden of treatment dominated preferences for surgery versus nonsurgical options. Interventions to aid treatment decision making should account for these elements to minimize the impact of physician biases and patient misperceptions on men's decisions as how best to manage their prostate cancer.

The impact of computerized provider order entry on medication errors in a multispecialty group practice

OBJECTIVE

Computerized provider order entry (CPOE) has been shown to improve patient safety by reducing medication errors and subsequent adverse drug events (ADEs). Studies demonstrating these benefits have been conducted primarily in the inpatient setting, with fewer in the ambulatory setting. The objective was to evaluate the effect of a basic, ambulatory CPOE system on medication errors and associated ADEs.

DESIGN

This quasiexperimental, pretest-post-test study was conducted in a community-based, multispecialty health system not affiliated with an academic medical center. The intervention was a basic CPOE system with limited clinical decision support capabilities.

MEASUREMENT

Comparison of prescriptions written before (n=5016 handwritten) to after (n=5153 electronically prescribed) implementation of the CPOE system. The primary outcome was the occurrence of error(s); secondary outcomes were types and severity of errors.

RESULTS

Frequency of errors declined from 18.2% to 8.2%-a reduction in adjusted odds of 70% (OR: 0.30; 95% CI 0.23 to 0.40). The largest reductions were seen in adjusted odds of errors of illegibility (97%), use of inappropriate abbreviations (94%) and missing information (85%). There was a 57% reduction in adjusted odds of errors that did not cause harm (potential ADEs) (OR 0.43; 95% CI 0.38 to 0.49). The reduction in the number of errors that caused harm (preventable ADEs) was not statistically significant, perhaps due to few errors in this category.

CONCLUSIONS

A basic CPOE system in a community setting was associated with a significant reduction in medication errors of most types and severity levels.

Electronic prescribing at the point of care: a time-motion study in the primary care setting

OBJECTIVE

To evaluate the impact of an ambulatory computerized provider order entry (CPOE ) system on the time efficiency of prescribers. Two primary aims were to compare prescribing time between (1) handwritten and electronic (e-) prescriptions and (2) e-prescriptions using differing hardware configurations.

DATA SOURCES/STUDY SETTING

Primary data on prescribers/staff were collected (2005-2007) at three primary care clinics in a community based, multispecialty health system.

STUDY DESIGN

This was a quasi-experimental, direct observation, time-motion study conducted in two phases. In phase 1 (n=69 subjects), each site used a unique combination of CPOE software/hardware (paper-based, desktops in prescriber offices or hallway workstations, or laptops). In phase 2 (n=77), all sites used CPOE software on desktops in examination rooms (at point of care).

DATA COLLECTION METHODS

Data were collected using TimerPro software on a Palm device.

PRINCIPAL FINDINGS

Average time to e-prescribe using CPOE in the examination room was 69 seconds/prescription-event (new/renewed combined)-25 seconds longer than to handwrite (99.5 percent confidence interval [CI] 12.38), and 24 seconds longer than to e-prescribe at offices/workstations (99.5 percent CI 8.39). Each calculates to 20 seconds longer per patient.

CONCLUSIONS

E-prescribing takes longer than handwriting. E-prescribing at the point of care takes longer than e-prescribing in offices/workstations. Improvements in safety and quality may be worth the investment of time.

Development of a population pharmacokinetics-based sampling schedule to target daily intravenous busulfan for outpatient clinic administration

Therapeutic drug monitoring of daily intravenous (IV) busulfan currently requires hospital admission. Population pharmacokinetic modeling and determination of an optimal pharmacokinetic sampling schedule over 6 hours could allow for personalizing these busulfan doses in the outpatient clinic. A retrospective evaluation of daily IV busulfan pharmacokinetics was conducted in 37 adults. SPK and NONMEM software were used to estimate the population pharmacokinetic parameters. Subsequent to model building, the area under the concentration-time curve (AUC) was computed using NONMEM. A 1-compartment model best fit the data. The optimal 6-hour outpatient sampling schedule was constructed using a simulation approach that sought to minimize scaled mean squared error for the clearance and volume parameters for each simulated individual. The best sampling times were 2.75, 3, 3.25, 5.5, 5.75, and 6 hours from the start of a 3-hour infusion. With these sampling times, the maximum a posteriori (MAP) Bayesian estimation was superior to maximum likelihood estimation with more samples. An individual patient's busulfan AUC and pharmacokinetic parameters may be accurately estimated with an outpatient sampling schedule that is used in conjunction with MAP Bayesian estimation, with a parameter prior based on population pharmacokinetic modeling. Prospective validation of this approach is needed.

Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications

OBJECTIVE

To examine the impact of a medication copayment increase on adherence to diabetes, hypertension, and hyperlipidemic medications.

STUDY DESIGN

Retrospective pre-post observational study.

METHODS

This study compared medication adherence at 4 Veterans Affairs medical centers between veterans who were exempt from copayments and propensity-matched veterans who were not exempt. The diabetes sample included 1069 exempt veterans and 1069 nonexempt veterans, the hypertension sample included 3545 exempt veterans and 3545 nonexempt veterans, and the sample of veterans taking statins included 2029 exempt veterans and 2029 nonexempt veterans. The main outcome measure was medication adherence 12 months before and 23 months after the copayment increase. Adherence differences were assessed in a difference-in-difference approach by using generalized estimating equations that controlled for time, copayment exemption, an interaction between time and copayment exemption, and patient demographics, site, and other factors.

RESULTS

Adherence to all medications increased in the short term for all veterans, but then declined in the longer term (February-December 2003). The change in adherence between the preperiod and the postperiod was significantly different for exempt and nonexempt veterans in all 3 cohorts, and nonadherence increased over time for veterans required to pay copayments. The impact of the copayment increase was particularly adverse for veterans with diabetes who were required to pay copayments.

CONCLUSION

A $5 copayment increase (from $2 to $7) adversely impacted medication adherence for veterans subject to copayments taking oral hypoglycemic agents, antihypertensive medications, or statins.

Discontinuation of radiation treatment among medicaid-enrolled women with local and regional stage breast cancer

For women with nonmetastatic breast cancer, radiation therapy is recommended as a necessary component of the breast conserving surgery (BCS) treatment option. The degree to which Medicaid-enrolled women complete recommended radiation therapy protocols is not known. We evaluate radiation treatment completion rates for Medicaid enrollees aged 18-64 diagnosed with breast cancer. We determine clinical and socio-demographic factors associated with not starting treatment, and with interruptions or not completing radiation treatment. Using data from the Washington State Cancer Registry linked to Medicaid enrollment and claims records, we identified Medicaid enrollees diagnosed with breast cancer from 1997 to 2003 who received BCS. Among the 402 women who met inclusion criteria, 105 (26%) did not receive any radiation. Factors significantly associated with not receiving radiation included in situ disease and non-English as a primary language. Among those who received at least one radiation treatment, 65 (22%) failed to complete therapy and 71 (24%) patients had at least one 5 to 30 day gap in treatment. We found no significant predictors of interruptions in treatment or early discontinuation. A substantial proportion of Medicaid-insured women who are eligible for radiation therapy following BCS either fail to receive any treatment, experience significant interruptions during therapy, or do not complete a minimum course of treatment. More effort is needed to ensure this vulnerable population receives adequate radiation following BCS.

Sensitivity of administrative claims to identify incident cases of lung cancer: a comparison of 3 health plans

BACKGROUND

Administrative claims are readily available, but their usefulness for identifying persons with non-small cell lung cancer (NSCLC) is relatively unknown, particularly for younger persons and those enrolled in Medicaid.

OBJECTIVES

To determine the sensitivity of ICD-9-CM codes for identifying persons with NSCLC.

METHODS

This was a retrospective analysis of insurance claims records linked to the Surveillance, Epidemiology, and End Results (SEER) cancer registry for the time period January 1, 2002, through December 31, 2005. Persons included in the sample were identified with NSCLC using SEER morphology and histology codes and were enrolled in a commercial health plan, Medicaid, or Medicare fee-for-service health plans in Washington State. The outcome measure was sensitivity, defined as the percentage of SEER-identified patients who were accurately identified as NSCLC cases using ICD-9-CM diagnoses (162.2, 162.3, 162.4, 162.5, 162.8, 162.9, or 231.2) recorded in any claim field in administrative claims data. We examined the influence of varying the number and timing of administrative codes in relation to the SEER cancer diagnosis date. In multivariate models, we examined the influence of age, sex, and comorbidity on sensitivity.

RESULTS

The sensitivity of 1 medical claim including at least 1 ICD-9-CM code for identifying NSCLC within 60 days of diagnosis as documented in the SEER registry was 51.1% for Medicaid, 87.7% for Medicare, and 99.4% for commercial plan members. Sensitivity can improve at the expense of identifying a portion of patients who are 3 or more months from their true diagnosis date. In multivariate models, age, race, and noncancer comorbidity but not gender significantly influenced sensitivity.

CONCLUSIONS

Administrative claims are sensitive for identifying patients with new NSCLC in the commercial and Medicare plans. For Medicaid patients, linkage with cancer registry records is needed to conduct studies using administrative claims.

A limited sampling schedule to estimate individual pharmacokinetic parameters of fludarabine in hematopoietic cell transplant patients

PURPOSE

Fludarabine monophosphate (fludarabine) is frequently administered to patients receiving a reduced-intensity conditioning regimen for allogeneic hematopoietic cell transplant (HCT) in an ambulatory care setting. These patients experience significant interpatient variability in clinical outcomes, potentially due to pharmacokinetic variability in 2-fluoroadenine (F-ara-A) plasma concentrations. To test such hypotheses, patient compliance with the blood sampling should be optimized by the development of a minimally intrusive limited sampling schedule (LSS) to characterize F-ara-A pharmacokinetics. To this end, we sought to create the first F-ara-A population pharmacokinetic model and subsequently a LSS.

EXPERIMENTAL DESIGN

A retrospective evaluation of F-ara-A pharmacokinetics was conducted after one or more doses of daily i.v. fludarabine in 42 adult HCT recipients. NONMEM software was used to estimate the population pharmacokinetic parameters and compute the area under the concentration-time curve.

RESULTS

A two-compartment model best fits the data. A LSS was constructed using a simulation approach, seeking to minimize the scaled mean squared error for the area under the concentration-time curve for each simulated individual. The LSS times chosen were 0.583, 1.5, 6.5, and 24 hours after the start of the 30-minute fludarabine infusion.

DISCUSSION

The pharmacokinetics of F-ara-A in an individual HCT patient can be accurately estimated by obtaining four blood samples (using the LSS) and maximum a posteriori Bayesian estimation.

CONCLUSION

These are essential tools for prospective pharmacodynamic studies seeking to determine if clinical outcomes are related to F-ara-A pharmacokinetics in patients receiving i.v. fludarabine in the ambulatory clinic.

Access to information sources and treatment considerations among men with local stage prostate cancer

OBJECTIVES

To determine the role of information sources in the treatment decision-making process of men diagnosed with local stage prostate cancer. Diagnosed men have access to a large number of information sources about therapy, including print and broadcast media, the Internet, books, and friends with the disease.

METHODS

Prospective survey of men with local stage prostate cancer in 3 geographically separate regions was carried out. Most men were surveyed after diagnosis but before starting therapy.

RESULTS

On average, men with local prostate cancer consulted nearly 5 separate sources of information before treatment. The most common source of information was the patient's physician (97%), followed by lay-literature (pamphlets, videos) (76%), other health professionals (71%), friends with prostate cancer (67%), and the Internet (58%). Most men rated the sources they consulted as helpful. Consulting the Internet was associated with considering more treatment options. Several information sources were significantly associated with considering particular treatments, but the magnitude of association was small in relation to patient age, comorbidity, and Gleason score. More than 70% of men stated that they were considering or planning only one type of therapy.

CONCLUSIONS

Men with local stage prostate cancer consult a wide range of information sources. Nonphysician information sources appear to influence their treatment considerations, but to a smaller degree than clinical factors.

Reduced duodenal cytochrome P450 3A protein expression and catalytic activity in patients with cirrhosis

The small intestine and liver express high levels of cytochrome P450 3A (CYP3A), an enzyme subfamily that contributes significantly to drug metabolism. In patients with cirrhosis, reduced metabolism of drugs is typically attributed to decreased liver function, but it is unclear whether drug metabolism in the intestine is also compromised. In this study, we compared CYP3A protein expression and in vitro midazolam hydroxylation in duodenal mucosal biopsies from subjects with normal liver function (controls; n = 20) and subjects with various levels of severity of cirrhosis (n = 23). In samples from subjects with cirrhosis, duodenal CYP3A expression and total midazolam hydroxylation were lower by 47 and 34%, respectively, as compared with samples from controls. Greater decreases in CYP3A expression were seen in subjects with more severe cirrhosis. Therefore, patients with advanced cirrhosis may have greater drug exposure following oral dosing as a result of both impaired liver function and decreased intestinal CYP3A expression and activity.

The impact of using different imputation methods for missing quality of life scores on the estimation of the cost-effectiveness of lung-volume-reduction surgery

A post hoc analysis of data from a prospective cost-effectiveness analysis (CEA) conducted alongside a randomized controlled trial (National Emphysema Treatment Trial - NETT) was used to assess the impact of using different imputation methods for missing quality of life data on the estimation of the incremental cost-effectiveness ratio (ICER). The NETT compared lung-volume-reduction surgery plus medical therapy with medical therapy alone in patients with severe chronic obstructive pulmonary disease due to emphysema. One thousand sixty-six patients were followed for up to 3 years after randomization. The cost per quality-adjusted life-year gained was obtained, computing costs from a societal perspective and using the self-administered Quality of Well Being questionnaire to measure quality of life. Different methods of imputation resulted in substantial differences in ICERs as well as differences in estimates of the uncertainty in the point estimates as reflected in the CEA acceptability curves. Paradoxically, the use of a conservative single imputation method resulted in relatively less uncertainty (anticonservative) about the ICER. Owing to the effects of different imputation methods for missing quality of life data on the estimation of the ICER, we recommend use of a minimum of two imputation methods that always include multiple imputation.

Comparison of guideline-based control definitions and associations with outcomes in severe or difficult-to-treat asthma

BACKGROUND

The National Asthma Education and Prevention Program put forth guidance on how to measure asthma control. This guidance is flexible regarding how the impairment component of control is assessed.

OBJECTIVES

To evaluate and compare 3 different National Asthma Education and Prevention Program-informed definitions of asthma control and to explore the strength of association between levels of asthma control and future control, asthma-related costs, and health-related quality-of-life utilities.

METHODS

We used descriptive statistics, the weighted K statistic, and regression methods to compare 3 definitions in a large registry cohort and to explore associations with clinical and health economic outcomes.

RESULTS

We followed up 3,061 patients (> or = 12 years old) in a representative sample of severe or difficult-to-treat asthma. At baseline, 9.1%, 17.1%, or 33.5% of patients were considered well controlled depending on the definition. Lung function was not a component of the definition where 33.5% of patients were well controlled. Weighted K statistics comparing the baseline control definitions ranged from 0.36 to 0.67. The adjusted R2 statistic from the models predicting the future odds of being well controlled, mean asthma-related costs, and mean utilities did not yield consistent results for ranking the definitions of control.

CONCLUSIONS

Although all 3 control definitions were correlated with future control and health economic outcomes, there were striking differences in the descriptive results across the definitions, including the proportion of patients in each category of control. Differences among definitions of asthma control may lead to divergent research conclusions or treatment practices. We do not advocate for one particular definition, but we call for standardization of control definitions for specific uses.

Population pharmacokinetics of cyclophosphamide and metabolites in children with neuroblastoma: a report from the Children's Oncology Group

Cyclophosphamide-based regimens are front-line treatment for numerous pediatric malignancies; however, current dosing methods result in considerable interpatient variability in tumor response and toxicity. In this pediatric population, the authors' objectives were (1) to quantify and explain the pharmacokinetic variability of cyclophosphamide and 2 of its metabolites, hydroxycyclophosphamide (HCY) and carboxyethylphosphoramide mustard (CEPM), and (2) to apply a population pharmacokinetic model to describe the disposition of cyclophosphamide and these metabolites. A total of 196 blood samples were obtained from 22 children with neuroblastoma receiving intravenous cyclophosphamide (400 mg/m2/d) and topotecan. Blood samples were quantitated for concentrations of cyclophosphamide, HCY, and CEPM using liquid chromatography-mass spectrometry and analyzed using nonlinear mixed-effects modeling with the NONMEM software system. After model building was complete, the area under the concentration-time curve (AUC) was computed using NONMEM. Cyclophosphamide elimination was described by noninducible and inducible routes, with the latter producing HCY. Glomerular filtration rate was a covariate for the fractional elimination of HCY and its conversion to CEPM. Considerable interpatient variability was observed in the AUC of cyclophosphamide, HCY, and CEPM. These results represent a critical first step in developing pharmacokinetic-linked pharmacodynamic studies in children receiving cyclophosphamide to determine the clinical relevance of the pharmacokinetic variability in cyclophosphamide and its metabolites.

Costs of pulmonary rehabilitation and predictors of adherence in the National Emphysema Treatment Trial

This study reports the costs associated with rehabilitation among participants in the National Emphysema Treatment Trial (NETT), and evaluates factors associated with adherence to rehabilitation. Pulmonary rehabilitation is recommended for moderate-to-severe COPD and required by the Centers for Medicare and Medicaid Services (CMS) prior to lung volume reduction surgery (LVRS). Between January 1998 and July 2002, 1,218 subjects with emphysema and severe airflow limitation (FEV(1) < or = 45% predicted) were randomized. Primary outcome measures were designated as mortality and maximal exercise capacity 2 years after randomization. Pre-randomization, estimated mean total cost per patient of rehabilitation was $2,218 (SD $314; 2006 dollars) for the medical group and $2,187 (SD $304) for the surgical group. Post-randomization, mean cost per patient in the medical and surgical groups was $766 and $962 respectively. Among patients who attended > or = 1 post-randomization rehabilitation session, LVRS patients, patients with an FEV(1) > or = 20% predicted, and higher education were significantly more likely to complete rehabilitation. Patients with depressive and anxiety symptoms, and those who live > 36 miles compared to < 6 miles away were less likely to be adherent. Patients who underwent LVRS completed more exercise sessions than those in the medical group and were more likely to be adherent with post-randomization rehabilitation. A better understanding of patient factors such as socioeconomic status, depression, anxiety and transportation issues may improve adherence to pulmonary rehabilitation.

The association between alcohol consumption and risk of COPD exacerbation in a veteran population

BACKGROUND

Alcohol has been associated with COPD-related mortality but has not yet been demonstrated to be an independent risk factor for COPD exacerbation. Our objective was to evaluate the association between alcohol consumption and the subsequent risk of COPD exacerbation.

METHODS

A prospective cohort study of general medicine outpatients seen at one of seven Veterans Affairs (VA) medical centers who returned health screening questionnaires. Three screening questionnaires, AUDIT-C (0 to 12 points), CAGE (0 to 4 points), and a single item about the frequency of drinking six or more drinks on an occasion (binge drinking), were used to classify alcohol consumption. The main outcome, COPD exacerbation, was based on primary VA discharge diagnosis (International Classification of Diseases, Ninth Revision) or outpatient diagnosis of COPD accompanied by prescriptions for either antibiotics or prednisone within 2 days.

RESULTS

Among the 30,503 patients followed up for a median of 3.35 years, those patients with AUDIT-C scores > or = 6, CAGE scores > or = 2, or who reported binge drinking at least weekly were at an increased risk of COPD exacerbation in age-adjusted analysis. Adjusted hazard ratios were 1.4 (95% confidence interval [CI], 1.1 to 1.7) for AUDIT-C score > or = 6, 1.4 (95% CI, 1.3 to 1.5) for CAGE score > or = 2, and 1.6 (95% CI, 1.2 to 2.2) for those who reported binge drinking daily or almost daily. However, with adjustment for measures of tobacco use, the association between alcohol consumption and increased risk of COPD exacerbation was no longer evident.

CONCLUSIONS

Alcohol consumption, whether quantified by AUDIT-C, CAGE score, or binge drinking, was not associated with an increased risk of COPD exacerbation independent of tobacco use.

Association of Preexisting Symptoms with Treatment Decisions among Newly Diagnosed Prostate Cancer Patients

BACKGROUND: The choice between surgical versus non-surgical treatment options is a fundamental decision for men with local stage prostate cancer because of differences in risks of genitourinary side effects among available treatments. OBJECTIVES: We assessed whether preexisting genitourinary symptoms at the time of diagnosis influenced men's preferences for surgery versus other management options. METHODS: We recruited 593 patients with newly diagnosed local stage prostate cancer prior to initiating treatment from an integrated health care system, an academic urology center, and community urology clinics. Using logistic regression we compared whether men had a preference for non-surgical options or only preferred surgery. RESULTS: Nearly 60% indicated they were considering non-surgical options. Age and clinical characteristics but not preexisting genitourinary symptoms influenced the decision between preferences for surgical or non-surgical options. A total of 62% of men reported side effects as a main factor in their treatment decision. Men with more aggressive tumor types were less likely to consider side effects, however, men who reported poor ability to have an erection were more likely to consider side effects (p<0.001). CONCLUSION: Sexual dysfunction at time of diagnosis, but not other genitourinary symptoms, is associated with men considering treatment-related side effects when considering surgery versus other options. Men who are not experiencing sexual dysfunction at diagnosis may discount the risks of side effects in the decision making process.

Second-line and third-line chemotherapy for lung cancer: use and cost

OBJECTIVES

To identify commonly prescribed first-, second-, and third-line chemotherapy regimens for persons with lung cancer and to evaluate the utilization patterns and costs of care associated with receiving these regimens.

STUDY DESIGN

Retrospective data analysis.

METHODS

Using health insurance claims from January 1, 2002, through December 31, 2006, patients with lung cancer were identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. An algorithm was developed to identify first-, second-, and third-line chemotherapy. Patients were stratified by the number of discrete regimens received or by their specific chemotherapy agent or combination of agents. Data were analyzed for up to 2 years from the date of the initial first-line regimen and for 1 year from the second and third lines. Patient costs were based on total reimbursements for each group during the observation period.

RESULTS

Of patients receiving first-line chemotherapy, 25% and 10% received second-line and third-line chemotherapy, respectively. Docetaxel, gefitinib, and erlotinib hydrochloride were the most commonly prescribed second-line regimens; gefitinib and docetaxel were the most commonly prescribed third-line regimens. The most commonly prescribed second- and third-line agents changed substantially over time. Total costs and costs per patient per month increased as the number of lines of chemotherapy prescribed increased.

CONCLUSIONS

Second- and third-line chemotherapy is prescribed infrequently, and patterns of prescribing are changing over time. Direct medical care costs increase substantially with additional lines of therapy.

A novel phenotypic method to determine fludarabine triphosphate accumulation in T-lymphocytes from hematopoietic cell transplantation patients

PURPOSE

Fludarabine is an integral anticancer agent for patients with chronic lymphocytic leukemia (CLL) and those receiving conditioning regimens prior to allogeneic hematopoietic cell transplantation (HCT). An individual's response to fludarabine may be influenced by the amount of CD4(+) and CD8(+) T-lymphocyte suppression. Fludarabine undergoes cellular uptake and activation to form the cytotoxic metabolite, fludarabine triphosphate (F-ara-ATP).

METHODS

We have previously developed a highly sensitive LC-MS method to quantitate intracellular F-ara-ATP concentrations in a leukemic cell line. However, quantitation of F-ara-ATP concentrations within CD4(+) and CD8(+) T-lymphocytes from pharmacokinetic blood samples obtained from patients receiving fludarabine therapy is not feasible because of the limited number of T-lymphocytes that can be isolated from each blood sample. Thus, we sought to determine F-ara-ATP accumulation after ex vivo exposure of freshly isolated human CD4(+) or CD8(+) T-lymphocytes to fludarabine. The method was optimized in T-lymphocytes obtained from healthy volunteers, and proved to be a feasible method to determine F-ara-ATP accumulation in patients undergoing HCT.

RESULTS

Considerable variability was observed in F-ara-ATP accumulation in HCT patients (10.5- and 12.5-fold in CD4(+) and CD8(+) cells, respectively), compared to healthy volunteers (1.6- and 1.9-fold in CD4(+) and CD8(+) cells, respectively). Larger variability was also observed in gene expression of transporters and enzymes involved in F-ara-ATP accumulation in HCT patients; however, F-ara-ATP accumulation was not correlated with gene expression, which is in agreement with previous studies.

CONCLUSIONS

The quantitation of F-ara-ATP accumulation in T-lymphocytes provides a novel tool to evaluate patient sensitivity to fludarabine. This tool can be used in future studies to evaluate whether intracellular F-ara-ATP accumulation is associated with efficacy and/or toxicity in patients receiving fludarabine.

Clinical and demographic characteristics help explain variations in pain at the end of life

The natural history of pain at the end of life is not well understood. The purpose of this study was to estimate the association between clinical and demographic characteristics and pain in persons who received hospice care in the United States. Data for this study were obtained from a national provider of hospice pharmacy services and included information about the hospice and person receiving hospice care, including geographic location, primary diagnoses, pain intensity, and opioid analgesic use. The data were collected from 2000 to 2004. Worst pain intensity during the previous 24 hours was assessed by the hospice nurse using a 0-10 numeric rating scale (0=none, 10=worst) at an average of 4.1 times per person during hospice care. Regression models were constructed to explain last and average pain scores using data from persons with at least two pain intensity scores. Hospice services were provided to 51,578 persons with at least two pain intensity scores. Of this cohort, 52% were female, 87.5% were Caucasian, and 66.4% had a primary diagnosis of cancer. The mean age at discharge or death was 73.8 years. Patient characteristics accounted for nearly one-third and nearly one-half of the variability in last and average pain scores, respectively. Severe pain on admission and frequency of pain reports were associated with less intense pain. Clinical and demographic characteristics contributed to identifying persons who had severe pain during their hospice admission. These data contribute to understanding pain in persons at the end of life.