1
|
Kanter J, Ataga KI, Bhasin N, Guarino S, Kutlar A, Lanzkron S, Manwani D, McGann P, Stowell SR, Tubman VN, Yermilov I, Campos C, Broder MS. Expert consensus on the management of infusion-related reactions (IRRs) in patients with sickle cell disease (SCD) receiving crizanlizumab: a RAND/UCLA modified Delphi panel. Ann Hematol 2024:10.1007/s00277-024-05736-6. [PMID: 38642304 DOI: 10.1007/s00277-024-05736-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 03/27/2024] [Indexed: 04/22/2024]
Abstract
Crizanlizumab, a monoclonal antibody against P-selectin, has been shown to reduce vaso-occlusive crises (VOCs) compared to placebo in patients ≥ 16 years with sickle cell disease (SCD). However, there have been rare reports of patients experiencing severe pain and subsequent complications within 24 hours of crizanlizumab infusions. These events are defined as infusion-related reactions (IRRs). Informed by current literature and clinical experience, a group of content experts developed clinical guidelines for the management of IRRs in patients with SCD. We used the RAND/University of California, Los Angeles (UCLA) modified Delphi panel method, a valid, reproducible technique for achieving consensus. We present our recommendations for managing IRRs, which depend on patient characteristics including: prior history of IRRs to other monoclonal antibodies or medications, changes to crizanlizumab infusion rate and patient monitoring, pain severity relative to patient's typical SCD crises, and severe allergic symptoms. These recommendations outline how to evaluate and manage IRRs in patients receiving crizanlizumab. Future research should validate this guidance using clinical data and identify patients at risk for these IRRs.
Collapse
Affiliation(s)
- Julie Kanter
- University of Alabama, Birmingham, Birmingham, AL, USA
| | - Kenneth I Ataga
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Neha Bhasin
- UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Stephanie Guarino
- ChristianaCare, Nemours Children's Health, Newark, Wilmington, DE, USA
| | | | | | - Deepa Manwani
- Children's Hospital at Montefiore, The Bronx, NY, USA
| | | | | | | | - Irina Yermilov
- PHAR (Partnership for Health Analytic Research), 280 S Beverly Dr, Suite 404, Beverly Hills, CA, 90212, USA.
| | - Cynthia Campos
- PHAR (Partnership for Health Analytic Research), 280 S Beverly Dr, Suite 404, Beverly Hills, CA, 90212, USA
| | - Michael S Broder
- PHAR (Partnership for Health Analytic Research), 280 S Beverly Dr, Suite 404, Beverly Hills, CA, 90212, USA
| |
Collapse
|
2
|
Gertz M, Abonour R, Gibbs SN, Finkel M, Landau H, Lentzsch S, Lin G, Mahindra A, Quock T, Rosenbaum C, Rosenzweig M, Sidana S, Tuchman SA, Witteles R, Yermilov I, Broder MS. Using a Modified Delphi Panel to Estimate Health Service Utilization for Patients with Advanced and Non-Advanced Systemic Light Chain Amyloidosis. CEOR 2023; 15:673-680. [PMID: 37719133 PMCID: PMC10503521 DOI: 10.2147/ceor.s412079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose Patients with diagnosed with systemic light chain (AL) amyloidosis at advanced Mayo stages have greater morbidity and mortality than those diagnosed at non-advanced stages. Estimating service use by severity is difficult because Mayo stage is not available in many secondary databases. We used an expert panel to estimate healthcare utilization among advanced and non-advanced AL amyloidosis patients. Patients and Methods Using the RAND/UCLA modified Delphi method, expert panelists completed 180 healthcare utilization estimates, consisting of inpatient and outpatient visits, testing, chemotherapy, and procedures by disease severity and organ involvement during two treatment phases (the 1 year after starting first line [1L] therapy and 1 year following treatment [post-1L]). Estimates were also provided for post-1L by hematologic treatment response (complete or very good partial response [CR/VGPR], partial, no response or relapse [PR/NR/R]). Areas of disagreement were discussed during a meeting, after which ratings were completed a second time. Results During 1L therapy, 55% of advanced patients had ≥1 hospitalization and 38% had ≥2 admissions. Rates of hematopoietic stem cell transplant (HSCT) in advanced patients were 5%, while pacemaker or implantable cardioverter defibrillator (ICD) placement were 15%. During post-1L therapy, rates of hospitalization in advanced patients remained high (≥1 hospitalization: 20-43%, ≥2 hospitalizations: 10-20%), and up to 10% of advanced patients had a HSCT. Ten percent of these patients underwent pacemaker/ICD placement. Conclusion Experts estimated advanced patients, who would not be good candidates for HSCT, would have high rates of hospitalization (traditionally the most expensive type of healthcare utilization) and other health service use. The development of new treatment options that can facilitate organ recovery and improve function may lead to decreased utilization.
Collapse
Affiliation(s)
- Morie Gertz
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rafat Abonour
- Department of Medicine, Indiana University School of Medicine; Director, Multiple Myeloma, Waldenstrom's Disease and Amyloidosis Program, Indianapolis, IN, USA
| | - Sarah N Gibbs
- PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
| | | | - Heather Landau
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Suzanne Lentzsch
- Multiple Myeloma and Amyloidosis Program, Columbia University Medical Center, New York, NY, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anuj Mahindra
- Malignant Hematology, Scripps Clinic MD Anderson Cancer Center, La Jolla, CA, USA
| | - Tiffany Quock
- Health Economics and Outcomes Research, Prothena Biosciences Ltd., South San Francisco, CA, USA
| | - Cara Rosenbaum
- Department of Medicine, Hematology/Oncology, Weill Cornell Medical College, New York, NY, USA
| | - Michael Rosenzweig
- Division of Multiple Myeloma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Surbhi Sidana
- Division of Cardiovascular Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | - Sascha A Tuchman
- Division of Hematology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Ronald Witteles
- Division of Cardiovascular Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | - Irina Yermilov
- PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
| | - Michael S Broder
- PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
| |
Collapse
|
3
|
Gibbs SN, Peneva D, Cuyun Carter G, Palomares MR, Thakkar S, Hall DW, Dalglish H, Campos C, Yermilov I. Comprehensive Review on the Clinical Impact of Next-Generation Sequencing Tests for the Management of Advanced Cancer. JCO Precis Oncol 2023; 7:e2200715. [PMID: 37285561 DOI: 10.1200/po.22.00715] [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] [Received: 12/27/2022] [Revised: 03/14/2023] [Accepted: 04/05/2023] [Indexed: 06/09/2023] Open
Abstract
PURPOSE This review summarizes the published evidence on the clinical impact of using next-generation sequencing (NGS) tests to guide management of patients with cancer in the United States. METHODS We performed a comprehensive literature review to identify recent English language publications that presented progression-free survival (PFS) and overall survival (OS) of patients with advanced cancer receiving NGS testing. RESULTS Among 6,475 publications identified, 31 evaluated PFS and OS among subgroups of patients who received NGS-informed cancer management. PFS and OS were significantly longer among patients who were matched to targeted treatment in 11 and 16 publications across tumor types, respectively. CONCLUSION Our review indicates that NGS-informed treatment can have an impact on survival across tumor types.
Collapse
Affiliation(s)
- Sarah N Gibbs
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | - Desi Peneva
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | | | | | | | | | - Hannah Dalglish
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | - Cynthia Campos
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| |
Collapse
|
4
|
Schwartzberg L, Broder MS, Ailawadhi S, Beltran H, Blakely LJ, Budd GT, Carr L, Cecchini M, Cobb P, Kansal A, Kim A, Monk BJ, Wong DJ, Campos C, Yermilov I. Impact of early detection on cancer curability: A modified Delphi panel study. PLoS One 2022; 17:e0279227. [PMID: 36542647 PMCID: PMC9770338 DOI: 10.1371/journal.pone.0279227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
Expert consensus on the potential benefits of early cancer detection does not exist for most cancer types. We convened 10 practicing oncologists using a RAND/UCLA modified Delphi panel to evaluate which of 20 solid tumors, representing >40 American Joint Committee on Cancer (AJCC)-identified cancer types and 80% of total cancer incidence, would receive potential clinical benefits from early detection. Pre-meeting, experts estimated how long cancers take to progress and rated the current curability and benefit (improvement in curability) of an annual hypothetical multi-cancer screening blood test. Post-meeting, experts rerated all questions. Cancers had varying estimates of the potential benefit of early cancer detection depending on estimates of their curability and progression by stage. Cancers rated as progressing quickly and being curable in earlier stages (stomach, esophagus, lung, urothelial tract, melanoma, ovary, sarcoma, bladder, cervix, breast, colon/rectum, kidney, uterus, anus, head and neck) were estimated to be most likely to benefit from a hypothetical screening blood test. Cancer types rated as progressing quickly but having comparatively lower cure rates in earlier stages (liver/intrahepatic bile duct, gallbladder, pancreas) were estimated to have medium likelihood of benefit from a hypothetical screening blood test. Cancer types rated as progressing more slowly and having higher curability regardless of stage (prostate, thyroid) were estimated to have limited likelihood of benefit from a hypothetical screening blood test. The panel concluded most solid tumors have a likelihood of benefit from early detection. Even among difficult-to-treat cancers (e.g., pancreas, liver/intrahepatic bile duct, gallbladder), early-stage detection was believed to be beneficial. Based on the panel consensus, broad coverage of cancers by screening blood tests would deliver the greatest potential benefits to patients.
Collapse
Affiliation(s)
- Lee Schwartzberg
- Division of Medical Oncology and Hematology, Renown Institute for Cancer, Reno, Nevada, United States of America
| | - Michael S. Broder
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
| | - Sikander Ailawadhi
- Department of Medicine, Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Himisha Beltran
- Department of Medical Oncology, Divisions of Genitourinary Oncology and Molecular and Cellular Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - L. Johnetta Blakely
- Health Economics and Outcomes Research, Tennessee Oncology, Nashville, Tennessee, United States of America
| | - G. Thomas Budd
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, United States of America
| | - Laurie Carr
- Department of Medicine, Division of Medical Oncology, National Jewish Health, Denver, Colorado, United States of America
| | - Michael Cecchini
- Department of Internal Medicine, Division of Medical Oncology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Patrick Cobb
- Oncology Research, Intermountain Healthcare, Billings, Montana, United States of America
| | - Anuraag Kansal
- Health Economics and Outcomes Research, GRAIL, LLC, a subsidiary of Illumina Inc., currently held separate from Illumina Inc. under the terms of the Interim Measures Order of the European Commission dated 29 October 2021, Menlo Park, California, United States of America
| | - Ashley Kim
- Health Economics and Outcomes Research, GRAIL, LLC, a subsidiary of Illumina Inc., currently held separate from Illumina Inc. under the terms of the Interim Measures Order of the European Commission dated 29 October 2021, Menlo Park, California, United States of America
- * E-mail:
| | - Bradley J. Monk
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, HonorHealth Research Institute, University of Arizona, Creighton University, Phoenix, Arizona, United States of America
| | - Deborah J. Wong
- Department of Medicine, Division of Hematology/Oncology, UCLA Health, Los Angeles, California, United States of America
| | - Cynthia Campos
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, California, United States of America
| |
Collapse
|
5
|
Greene N, Araujo L, Campos C, Dalglish H, Gibbs S, Yermilov I. The Economic and Humanistic Burden of Pediatric-Onset Multiple Sclerosis. J Health Econ Outcomes Res 2022; 9:103-114. [PMID: 36348724 PMCID: PMC9584745 DOI: 10.36469/001c.37992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/29/2022] [Indexed: 06/16/2023]
Abstract
Background: Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system. Pediatric-onset MS (POMS), defined as onset of MS before 18 years of age, is estimated to account for 2% to 5% of the MS population worldwide. Objectives: To conduct a literature review focused on the healthcare resource utilization and cost as well as quality-of-life (QOL) outcomes among patients with POMS. Methods: We conducted a systematic literature review of English-language studies published after September 2010 in MEDLINE and Embase to describe the global economic healthcare resource utilization and costs and humanistic (QOL) burden in patients with POMS. Results: We found 11 studies that reported on healthcare resource utilization, cost, or insurance coverage and 36 studies that reported on QOL outcomes in patients with POMS. Patients with POMS had higher rates of primary care visits (1.41 [1.29-1.54]), hospital visits (10.74 [8.95-12.90]), and admissions (rate ratio, 4.27 [2.92-6.25];OR, 15.2 [12.0-19.1]) compared with healthy controls. Mean per-patient costs in the United States were $5907 across all settings per year of follow-up between 2002 and 2012; mean costs per hospital stay were $38 543 (in 2015 USD) between 2004 and 2013. Three studies reported psychosocial scores between 71.59 and 79.7, and 8 studies reported physical health scores between 74.62 to 82.75 using the Pediatric Quality of Life Measurement Model (PedsQLTM). Twelve studies used the PedsQL™ Multidimensional Fatigue Scale. Mean scores on the self-reported general fatigue scale ranged from 63.15 to 78.5. Quality-of-life scores were lower than those of healthy controls. Discussion: Our review presents a uniquely broad and recent overview of the global economic and humanistic burden of patients with POMS. Additional research on healthcare resource utilization and cost would provide a more robust understanding of the economic burden in this population. Conclusions: Healthcare resource utilization and costs are high in this population, and patients report reduced QOL and significant fatigue compared with healthy children and adolescents.
Collapse
Affiliation(s)
- Nupur Greene
- Health Economics & Value Assessment, Sanofi, Cambridge, Massachusetts
| | - Lita Araujo
- Health Economics & Value Assessment, Sanofi, Cambridge, Massachusetts
| | - Cynthia Campos
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Hannah Dalglish
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Sarah Gibbs
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Irina Yermilov
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| |
Collapse
|
6
|
Broder MS, Gibbs SN, Yermilov I. An Adaptation of the RAND/UCLA Modified Delphi Panel Method in the Time of COVID-19. J Healthc Leadersh 2022; 14:63-70. [PMID: 35634010 PMCID: PMC9130741 DOI: 10.2147/jhl.s352500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/26/2022] [Indexed: 12/02/2022] Open
Abstract
The RAND/UCLA modified Delphi panel method is a formal group consensus process that systematically and quantitatively combines expert opinion and evidence by asking panelists to rate, discuss, then re-rate items. The method has been used to develop medical society guidelines, other clinical practice guidelines, disease classification systems, research agendas, and quality improvement interventions. Traditionally, a group of experts meet in person to discuss results of a first-round survey. After the meeting, experts complete a second-round survey used to develop areas of consensus. During the COVID-19 pandemic, this aspect of the method was not possible. As such, we have adapted the method to conduct virtual RAND/UCLA modified Delphi panels. In this study, we present a targeted literature review to describe and summarize the existing evidence on the RAND/UCLA modified Delphi panel method and outline our adaptation for conducting these panels virtually. Transitioning from in-person to virtual meetings was not without challenges, but there have also been unexpected advantages. The method we describe here can be a cost-effective and efficient alternative for researchers and clinicians.
Collapse
Affiliation(s)
- Michael S Broder
- Outcomes Research, Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
- Correspondence: Michael S Broder, Partnership for Health Analytic Research (PHAR), LLC, 280 S Beverly Drive, Suite 404, Beverly Hills, CA, 90212, USA, Tel +1-310-858-9555, Fax +1-310-858-9550, Email
| | - Sarah N Gibbs
- Outcomes Research, Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | - Irina Yermilov
- Outcomes Research, Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| |
Collapse
|
7
|
Duroseau Y, Beenhouwer D, Broder MS, Brown B, Brown T, Gibbs SN, Jackson K, Liang S, Malloy M, Romney M, Shani D, Simon J, Yermilov I. Developing an emergency department order set to treat acute pain in sickle cell disease. J Am Coll Emerg Physicians Open 2021; 2:e12487. [PMID: 34401866 PMCID: PMC8349222 DOI: 10.1002/emp2.12487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
STUDY OBJECTIVE Patients with sickle cell disease (SCD) have many emergency department visits because of painful vaso-occlusive episodes (VOE). Guidelines recommend treatment within 30 minutes of triage, but this is rarely achieved in clinical practice. Our goal was to develop an order set that is being implemented in the ED to facilitate and standardize emergency care for SCD patients in acute pain from VOEs presenting to the emergency department (ED) in New York City (NYC). METHODS Using a RAND/University of California, Los Angeles modified Delphi panel, we convened a multidisciplinary panel and reviewed evidence on how to best manage SCD pain in the ED. Panelists collaboratively developed then rated 202 items that could be included in an ED order set. RESULTS A consensus order set, a practical how-to guide for managing SCD pain in the ED, was developed based on items that received high median ratings. CONCLUSIONS The management of acute pain experienced during VOEs is critical to patients with SCD; ED order sets, such as this one, can help standardize pain management, including at triage, evaluation, discharge, and follow-up care. After implementation in NYC EDs, studies to examine changes in quality care metrics (eg, wait times, readmissions) are planned.
Collapse
Affiliation(s)
- Yves Duroseau
- Department of Emergency MedicineLenox Hill Hospital/Northwell HealthNew YorkNew YorkUSA
| | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Michael S Broder
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Bonnie Brown
- Observation MedicineMount Sinai Morningside and WestNew YorkNew YorkUSA
| | - Tartania Brown
- Metropolitan Jewish Healthcare SystemDepartment of Family and Social MedicineAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Sarah N Gibbs
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| | - Kaedrea Jackson
- Department of Emergency MedicineMount Sinai MorningsideNew YorkNew YorkUSA
| | - Sally Liang
- Mount Sinai Beth IsraelEmergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Melanie Malloy
- Emergency MedicineMount Sinai BrooklynIcahn School of Medicine at Mount SinaiBrooklynNew YorkUSA
| | - Marie‐Laure Romney
- Quality and Patient SafetyDepartment of Emergency MedicineColumbia UniversityNew YorkNew YorkUSA
| | - Dana Shani
- Departments of Hematology, Medical Oncology and Internal MedicineLenox Hill Hospital/Northwell HealthNew YorkNew YorkUSA
| | - Jena Simon
- Adult Program for Sickle Cell at Mount Sinai HospitalNew YorkNew YorkUSA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR)Beverly HillsCaliforniaUSA
| |
Collapse
|
8
|
Broder MS, Ailawadhi S, Beltran H, Blakely LJ, Budd GT, Carr L, Cecchini M, Cobb PW, Gibbs SN, Kansal A, Kim A, Monk BJ, Schwartzberg LS, Wong DJ, Yermilov I. Estimates of stage-specific preclinical sojourn time across 21 cancer types. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18584] [Citation(s) in RCA: 1] [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
e18584 Background: Cancer progression rates following diagnosis are readily measured. However, the progression rate of cancer during the preclinical sojourn time is generally unobserved. Understanding the duration of preclinical stages (“dwell time”) would allow clinicians to better identify appropriate screening intervals for cancer. We therefore elicited estimates of progression rate during the preclinical sojourn time for a wide variety of malignancies from a panel of clinical experts. Methods: We used a validated consensus methodology (RAND/UCLA modified Delphi panel method) to elicit per-stage dwell time estimates for 20 solid cancers and lymphoma from experts. Eleven experienced oncologists (general and subspecialists) from community and academic centers reviewed literature on the natural history of disease and estimated in number of years (<1 to 9+ years) how long it would take each cancer to progress from the beginning of clinically detectable Stage I/II/III to the beginning of the next stage in untreated adults. Cancer histological subtypes were grouped and experts were asked to provide an overall rating. Ratings were completed before and after a discussion of areas of disagreement. Results: Expert estimates and range of dwell time for 21 cancer types are provided in Table. Prostate and thyroid cancer were estimated to be the slowest growing, taking approximately 7 and 5 years respectively to progress through Stage I (range 4-8), 5 years to progress through Stage II (range 3-7), and 3 and 4 (range 2-5) years respectively to progress through Stage III. Esophageal, lung, liver/intrahepatic bile-duct, gallbladder, and pancreatic cancers were estimated to progress quickly through all three stages (1-2 years per stage). Conclusions: These findings summarize practicing oncologists’ estimates of dwell time in preclinical disease. Experts agreed on dwell times although ranges were large and differences in cancer subtypes were not captured. Generally, estimates trend with published data on survival with treatment: cancers with higher survival (e.g., prostate, thyroid) were estimated to grow slower, while cancers with lower survival (e.g., pancreatic, liver/intrahepatic bile-duct, gallbladder) were estimated to grow faster. These estimates could be useful when determining screening intervals for these or any subset of these cancers. [Table: see text]
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Sarah N. Gibbs
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | | | | | - Bradley J. Monk
- Arizona Oncology (US Oncology Network), University of Arizona, Creighton University, Phoenix, AZ
| | | | | | - Irina Yermilov
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| |
Collapse
|
9
|
Han X, Lobo F, Broder MS, Chang E, Gibbs SN, Ridley DJ, Yermilov I. Persistence with Early-Line Abatacept versus Tumor Necrosis Factor-Inhibitors for Rheumatoid Arthritis Complicated by Poor Prognostic Factors. J Health Econ Outcomes Res 2021; 8:71-78. [PMID: 34046511 PMCID: PMC8133796 DOI: 10.36469/jheor.2021.23684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by joint swelling and destruction that leads to severe disability. There are no clear guidelines regarding the order of therapies. Gathering data on treatment patterns outside of a clinical trial setting can provide useful context for clinicians. Objectives: To assess real-world treatment persistence in early-line abatacept versus tumor necrosis factor-inhibitors (TNFi) treated patients with RA complicated by poor prognostic factors (including anti-cyclic citrullinated peptide antibodies [ACPA] and rheumatoid factor [RF] seropositivity). Methods: We performed a multi-center retrospective medical record review. Adult patients with RA complicated by poor prognostic factors were treated with either abatacept or TNFis as the first biologic treatment at the clinic. Poor prognostic factors included ACPA+, RF+, increased C-reactive protein levels, elevated erythrocyte sedimentation rate levels, or presence of joint erosions. We report 12-month treatment persistence, time to discontinuation, reasons for discontinuation, and risk of discontinuation between patients on abatacept versus TNFi. Select results among the subgroup of ACPA+ and/or RF+ patients are presented. Results: Data on 265 patients (100 abatacept, 165 TNFis) were collected. At 12 months, 83% of abatacept patients were persistent versus 66.1% of TNFi patients (P=0.003). Median time to discontinuation was 1423 days for abatacept versus 690 days for TNFis (P=0.014). In adjusted analyses, abatacept patients had a lower risk of discontinuing index treatment due to disease progression (0.3 [95% confidence interval (CI): 0.1-0.6], P=0.001). Among the subgroup of ACPA+ and/or RF+ patients (55 abatacept, 108 TNFis), unadjusted 12-month treatment persistence was greater (83.6% versus 64.8%, P=0.012) and median time to discontinuation was longer (961 days versus 581 days, P=0.048) in abatacept versus TNFi patients. Discussion: Patients with RA complicated by poor prognostic factors taking abatacept, including the subgroup of patients with ACPA and RF seropositivity, had statistically significantly higher 12-month treatment persistence and a longer time to discontinuation than patients on TNFis. Conclusions: In a real-world setting, RA patients treated with abatacept were more likely to stay on treatment longer and had a lower risk of discontinuation than patients treated with TNFis.
Collapse
Affiliation(s)
- Xue Han
- Bristol-Myers Squibb Company, Health Economics and Outcomes Research, Princeton, NJ
| | - Francis Lobo
- Bristol-Myers Squibb Company, Health Economics and Outcomes Research, Princeton, NJ
| | - Michael S Broder
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | - Eunice Chang
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | - Sarah N Gibbs
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| | | | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA
| |
Collapse
|
10
|
Cuker A, Despotovic JM, Grace RF, Kruse C, Lambert MP, Liebman HA, Lyons RM, McCrae KR, Pullarkat V, Wasser JS, Beenhouwer D, Gibbs SN, Yermilov I, Broder MS. Tapering thrombopoietin receptor agonists in primary immune thrombocytopenia: Expert consensus based on the RAND/UCLA modified Delphi panel method. Res Pract Thromb Haemost 2021; 5:69-80. [PMID: 33537531 PMCID: PMC7845076 DOI: 10.1002/rth2.12457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombopoietin receptor agonists (TPO-RAs) are used to treat primary immune thrombocytopenia (ITP). Some patients have discontinued treatment while maintaining a hemostatic platelet count. OBJECTIVES To develop expert consensus on when it is appropriate to consider tapering TPO-RAs in ITP, how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy. METHODS We used a RAND/UCLA modified Delphi panel method. Ratings were completed independently by each expert before and after a meeting. Second-round ratings were used to develop the panel's guidance. The panel was double-blinded: The sponsor and nonchair experts did not know each other's identities. RESULTS Guidance on when it is appropriate to taper TPO-RAs in children and adults was developed based on patient platelet count, history of bleeding, intensification of treatment, trauma risk, and use of anticoagulants/platelet inhibitors. For example, it is appropriate to taper TPO-RAs in patients who have normal/above-normal platelet counts, have no history of major bleeding, and have not required an intensification of treatment in the past 6 months; it is inappropriate to taper TPO-RAs in patients with low platelet counts. Duration of ITP, months on TPO-RA, or timing of platelet response to TPO-RA did not have an impact on the panel's guidance on appropriateness to taper. Guidance on how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy is also provided. CONCLUSION This guidance could support clinical decision making and the development of clinical trials that prospectively test the safety of tapering TPO-RAs.
Collapse
Affiliation(s)
- Adam Cuker
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Rachael F. Grace
- Dana‐Farber/Boston Children’s Cancer and Blood Disorders CenterHarvard Medical SchoolBostonMAUSA
| | | | - Michele P. Lambert
- Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- University of Southern California, Norris Cancer HospitalLos AngelesCAUSA
| | | | | | | | | | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Sarah N. Gibbs
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Michael S. Broder
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| |
Collapse
|
11
|
Shah N, Beenhouwer D, Broder MS, Bronte-Hall L, De Castro LM, Gibbs SN, Gordeuk VR, Kanter J, Klings ES, Lipato T, Manwani D, Scullin B, Yermilov I, Smith WR. Development of a Severity Classification System for Sickle Cell Disease. Clinicoecon Outcomes Res 2020; 12:625-633. [PMID: 33149635 PMCID: PMC7604906 DOI: 10.2147/ceor.s276121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/16/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose There is no well-accepted classification system of overall sickle cell disease (SCD) severity. We sought to develop a system that could be tested as a clinical outcome predictor. Patients and Methods Using validated methodology (RAND/UCLA modified Delphi panel), 10 multi-disciplinary expert clinicians collaboratively developed 180 simplified patient histories and rated each on multiple axes (estimated clinician follow-up frequency, risk of complications or death, quality of life, overall disease severity). Using ratings on overall disease severity, we developed a 3-level severity classification system ranging from Class I (least severe) to Class III (most severe). Results The system defines patients as Class I who are 8-40 years with no end organ damage, no chronic pain, and ≤4 unscheduled acute care visits due to vaso-occlusive crises (VOC) in the last year. Patients <8 or >40 years with no end organ damage, no chronic pain, and <2 unscheduled acute care visits are also considered Class I. Patients any age with ≥5 unscheduled acute care visits and/or with severe damage to bone, retina, heart, lung, kidney, or brain are classified as Class III (except patients ≥25 years with severe retinopathy, no chronic pain, and 0-1 unscheduled acute care visits, who are considered Class II). Patients not meeting these Class I or III definitions are classified as Class II. Conclusion This system consolidates patient characteristics into homogenous groups with respect to disease state to support clinical decision-making. The system is consistent with existing literature that increased unscheduled acute care visits and organ damage translate into clinically significant patient morbidity. Studies to further validate this system are planned.
Collapse
Affiliation(s)
- Nirmish Shah
- Department of Medicine, Duke University, Durham, NC, USA
| | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | - Michael S Broder
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | | | - Laura M De Castro
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sarah N Gibbs
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | - Victor R Gordeuk
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Julie Kanter
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth S Klings
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Thokozeni Lipato
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Brigid Scullin
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, USA
| | - Wally R Smith
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
12
|
Abstract
OBJECTIVE To better understand the humanistic and economic burden of focal seizures in children 2-12 years old. METHODS We conducted a targeted literature review by searching MEDLINE for English-language publications reporting on children 2-12 years old with focal seizures published in the United States since 2008. RESULTS Thirty-five publications were included. Incidence of focal seizures was 23.2 to 47.1 per 100,000 children per year; prevalence was 2.0 per 1,000 children, and ranged from 1.6 - 2.6 per 1,000 in patients of any age. Life expectancy was 47.3-61.8 years among children 3-12 years old. Patients took several antiepileptic drugs and experienced frequent seizures, sleep disorders, mood disorders, migraine, and seizure-related injuries (eg, bone fractures, sprains, open wounds). Children with focal seizures scored below average on cognitive assessments and up to 42%, 16%, and 19% had depression, anxiety, and attention-deficit disorder, respectively. Patients of any age had about 10 outpatient visits (2 epilepsy-related), 2 inpatient visits (less than 1 epilepsy-related), and 24 procedures (1 epilepsy-related) per year. Medication adherence was low: only half of pediatric patients maintained ≥90% adherence over 6 months. Annual total health care costs among patients of any age ranged from $18,369 - 38,549; first-year total health care costs for children were $19,883. CONCLUSIONS Incidence and prevalence of focal seizures is high and the humanistic and economic burdens are significant. Future studies focused exclusively on children with focal seizures are needed to more precisely describe the burden. We also suggest further research and implementation of methods to improve medication adherence as an approach to lessen burden on these young patients.
Collapse
Affiliation(s)
- Sarah N Gibbs
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | | | | | - K Hamzah Ahmed
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Irina Yermilov
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Eric Segal
- Northeast Regional Epilepsy Group, Hackensack, NJ Hackensack University Medical Center, Hackensack, NJ, USA.,Seton Hall School of Medicine, Nutley, NJ, USA
| |
Collapse
|
13
|
Han X, Yermilov I, Gibbs S, Broder M. AB0294 PERSISTENCE WITH ABATACEPT VERSUS TUMOR NECROSIS FACTOR-INHIBITORS FOR RHEUMATOID ARTHRITIS COMPLICATED BY POSITIVE ANTI-CYCLIC CITRULLINATED PEPTIDE/RHEUMATOID FACTOR OR OTHER POOR PROGNOSTIC FACTORS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Rheumatoid arthritis (RA) treatment usually begins with a non-biologic disease-modifying antirheumatic drug (DMARD), followed by a biologic DMARD (including abatacept or tumor necrosis factor-inhibitors [TNFis]) in non-responsive patients.1Since, treatments are switched if disease activity does not improve, it is valuable to understand treatment persistence and switch patterns in RA patients with poor prognostic factors in a real-world setting.Objectives:To assess 12-month treatment persistence in early-line abatacept versus TNFi treated patients with RA complicated by poor prognostic factors.Methods:We performed a multi-center retrospective medical record review of adult RA patients with poor prognostic factors treated at 6 United States clinics. Patients were treated with abatacept or TNFi as the first biologic treatment at the clinic. Poor prognostic factors included positive anti-cyclic citrullinated peptide antibodies (ACPA+), positive rheumatoid factor antibodies (RF+), increased C-reactive protein levels, elevated erythrocyte sedimentation rate levels, or presence of joint erosions. TNFis included adalimumab, etanercept, infliximab (and their biosimilars), certolizumab pegol, or golimumab. Data were collected from first biologic treatment for ≥1 year. Patients with Crohn’s disease, ankylosing spondylitis, ulcerative colitis, psoriatic arthritis, or anal fistula were excluded. Demographic, disease, and treatment information (start, stop, reason for discontinuation) was abstracted. Treatment persistence (continuation of index treatment with gap ≤60 days) at 12 months and time to discontinuation were reported. Multivariate logistic and Cox regressions were used to compare 12-month persistence and risk of discontinuation between abatacept and TNFi, controlling for demographic and clinical characteristics (age, sex, Charlson comorbidity index [CCI], RA duration), baseline utilization, and clinic. Findings among a subgroup of ACPA+ and/or RF+ patients are reported.Results:Data on 265 patients (100 abatacept, 165 TNFi) were collected, including 163 ACPA+ and/or RF+ patients (55 abatacept, 108 TNFi). Overall, abatacept patients were older than TNFi patients (67.0 vs. 60.3 years, p<0.001), but there were no statistically significant differences in gender, comorbidities, or duration of treatment at the clinic. At 12 months, 83.0% of abatacept patients were persistent vs. 66.1% of TNFi patients (p=0.003). Persistence was similar among ACPA+ and/or RF+ patients (83.6% vs. 64.8%, p=0.012). Median time to discontinuation was 1,423 days for abatacept vs. 690 days for TNFi (p=0.014) (961 days vs. 581 days among ACPA+ and/or RF+ patients, p=0.048) (Figures 1,2). In the adjusted analysis, risk of all-cause discontinuation was statistically significantly higher among TNFi than abatacept patients (1.7 [95% CI: 1.1-2.6], p=0.012). The odds of TNFi patients being persistent at 12 months was 51% lower than abatacept patients, although not statistically significant (p=0.071). More TNFi than abatacept patients discontinued index treatment due to disease progression (27.3% vs. 12.0%, p=0.003). Adjusted analyses showed that TNFi patients had a statistically significantly higher risk of discontinuing index treatment due to disease progression (3.4 [95% CI: 1.6-7.2], p=0.001).Figure 1.Time to discontinuation of index treatment among all patients (N=265)Conclusion:In a real-world setting, RA patients with ACPA or RF positivity or other poor prognostic factors are less likely to discontinue abatacept compared with TNFi and are more likely to be persistent on their early line treatment. This difference may be explained by the lower proportion of patients discontinuing abatacept due to disease progression.References:[1]Singh et al.Arthritis Care Res. 2012;64(5):625-639. doi:10.1002/acr.21641Figure 2.Time to discontinuation of index treatment among ACPA+ and/or RF+ patients (N=163)Disclosure of Interests:Xue Han Employee of: BMS, Irina Yermilov Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract., Sarah Gibbs Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract., Michael Broder Employee of: I am an employee of the Partnership for Health Analytic Research (PHAR) LLC, which was paid by BMS to conduct the research described in this abstract.
Collapse
|
14
|
Schwartzberg L, Chatterjee D, Knoth R, Gibbs SN, Ahmed KH, Broder MS, Yermilov I. Abstract P2-15-13: A time-and-motion study of chemotherapy administration in metastatic breast cancer. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p2-15-13] [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: 11/16/2022]
Abstract
Abstract
Background: Ordering and delivering chemotherapy is complex, impacting patient and caregiver quality of life. Metastatic breast cancer (mBC) patients receive intravenous chemotherapy with variable administration times and patient satisfaction may differ by session length. We investigated common chemotherapy agents for mBC through a time and motion analysis. Methods: We conducted a prospective, observational time-and-motion study of adult females with mBC receiving ≥ 2nd-line eribulin, vinorelbine (VI), or gemcitabine (GC) at a large community oncology clinic. An observer documented times events occurred (Table). Patients completed a satisfaction survey adapted from Agency for Healthcare Research and Quality’s cancer care survey and the Cancer Therapy Satisfaction Questionnaire. Event times were compared using t-test. Spearman’s rank correlation was used to test correlations between time and satisfaction. Results: 17 patients (11 eribulin, 6 VI/GC) comprising 31 observations (20 eribulin, 11 VI/GC) were included in the preliminary analysis. Patients were 65 years on average, 71% white, and 94% post-menopausal; all were HER-2-. Mean years since mBC diagnosis was lower for eribulin than VI/GC patients (1.7 vs 5.0, p<0.009). Chemotherapy administration was shorter for eribulin patients (Table). 82% of patients were very satisfied with their cancer care experience; satisfaction did not correlate with event times. Conclusions: Eribulin administration time was significantly lower than VI/GC in mBC patients while maintaining similar satisfaction levels. These preliminary results demonstrate novel treatments for mBC can shorten treatment administration time while providing patient-centered, coordinated care. Table. Observation by event (mean minutes)
All observationsEribulin Vinorelbine/ GemcitabineP value *<0.05Chair time (total time patient was in chair)7367840.174Chemotherapy ordered to chemotherapy end5449610.080Chemotherapy ordered to discharge6557740.111Chemotherapy arrived chair-side to chemotherapy end1510230.003*Chemotherapy arrived chair-side to discharge2620370.007*Chemotherapy administration (medication start to end)116200.001*
Citation Format: Lee Schwartzberg, Debanjana Chatterjee, Russel Knoth, Sarah N Gibbs, K Hamzah Ahmed, Michael S Broder, Irina Yermilov. A time-and-motion study of chemotherapy administration in metastatic breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-15-13.
Collapse
Affiliation(s)
| | | | | | - Sarah N Gibbs
- 4Partnership for Health Analytic Research, Beverly Hills, CA
| | - K Hamzah Ahmed
- 4Partnership for Health Analytic Research, Beverly Hills, CA
| | | | - Irina Yermilov
- 4Partnership for Health Analytic Research, Beverly Hills, CA
| |
Collapse
|
15
|
Abstract
Background Workplace health screening offers a unique opportunity to assess individuals for type 2 diabetes mellitus. Aims To evaluate the association between workplace diabetes screening, subsequent diagnosis and changes in fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) and body mass index (BMI) among individuals who screened positive for diabetes. Methods Employees without a prior diagnosis of diabetes participated in workplace health screening by 45 employers throughout the USA. Individuals screened positive for diabetes based on standard criteria (≥126 mg/dL FPG or ≥6.5% [48 mmol/mol] HbA1c). Diabetes diagnoses were identified after screening using claims-based ICD9-CM diagnosis codes. Discrete-time survival analysis estimated the monthly rate of new diabetes cases after screening, relative to the time period before screening. Paired t-tests evaluated 1-year changes in blood glucose measures and BMI among individuals with positive screenings. Results Of 22790 participating individuals, 900 (4%) screened positive for diabetes. A significantly greater rate of new diabetes diagnoses was observed during the first month after screening, compared to the 3-month period before screening (odds ratio [OR] 2.65, 95% confidence intervals [CIs] 2.02-3.47). Among 538 individuals with diabetes who returned for workplace screening 1 year later, significant improvements were observed in BMI (mean ± SD = -0.63 ± 2.56 kg/m2, P < 0.001) and FPG levels (mean ± SD = -9.3 ± 66.5 mg/dL, P < 0.01). Conclusions Workplace screening was associated with a reduction in the number of undiagnosed employees with diabetes and significant improvement in FPG and BMI at 1-year follow-up.
Collapse
Affiliation(s)
- V Bali
- e2H, West Corporation, Westlake Village, CA, USA
| | - I Yermilov
- e2H, West Corporation, Westlake Village, CA, USA
| | - A Koyama
- Centre for Health Systems and Safety Research, Macquarie University, North Ryde, New South Wales, Australia
| | - A P Legorreta
- Department of Health Policy and Management, University of California, Los Angeles, School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
16
|
Broder M, Patel H, Wessler Z, Gibbs S, Yermilov I, Lemay J. Use of a modified Delphi panel to define value of combination therapy in oncology. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e18369] [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
e18369 Background: Treatment regimens involving 2+ novel oncologics have improved health outcomes in several tumor types. These regimens have significantly higher costs than single agents and older treatments (e.g., chemotherapies), which are still widely used to treat different cancers. Our goal was to determine if current concepts of “value,” such as those described by ICER and other frameworks, adequately capture the value of combination therapies. Methods: Using a RAND/UCLA modified Delphi panel, 8 experts from various backgrounds were provided with a review of current concepts of value and asked to rate them on measurability, relevance, and necessity to determine a combination therapy’s value from 4 perspectives (patient, physician, payer, society). After the first round of ratings, panelists met in person and discussed areas of disagreement. Ratings were repeated, and results used to quantitatively summarize group opinion on concepts recommended for inclusion in a value definition. Results: In both rating rounds, experts agreed treatment, clinical evidence, and health outcomes as important domains in determining value. Experts disagreed on whether societal/cultural beliefs, disease factors (i.e., rarity of cancer, unmet need, burden of disease), and other elements of value (e.g., insurance value, reduction in uncertainty, treatment affordability) needed to be incorporated into value assessments of combinations. Responses differed by perspective. Concepts on which there was disagreement decreased post-meeting (23% to 9%). Conclusions: Experts agreed that “value” for 2+ novel oncologics would have a similar definition to value for all high cost oncology therapies. Four key research opportunities to characterize the value of combination therapy emerged: societal context and patient preference may affect value assessments but are not widely considered in current models; some important benefits are not recognized by patients and may be missed by traditional value assessments; given typical patient and societal preferences, cancer treatments may be systematically undervalued vis a vis other health conditions; and combination therapies may present challenges for recently promulgated value frameworks.
Collapse
Affiliation(s)
- Michael Broder
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | | | | | - Sarah Gibbs
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Irina Yermilov
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | | |
Collapse
|
17
|
Broder MS, Greene M, Yan T, Chang E, Hartry A, Yermilov I. Medication Adherence, Health Care Utilization, and Costs in Patients With Major Depressive Disorder Initiating Adjunctive Atypical Antipsychotic Treatment. Clin Ther 2019; 41:221-232. [PMID: 30616973 DOI: 10.1016/j.clinthera.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study was to compare medication adherence, health care utilization, and cost among patients receiving adjunctive treatment for major depressive disorder (MDD) with brexpiprazole, quetiapine, or lurasidone. METHODS Using Truven Health MarketScan® Commercial, Medicaid, and Medicare Supplemental Databases, we identified adults with MDD initiating adjunctive treatment with brexpiprazole, quetiapine, or lurasidone (index atypical antipsychotic [AAP]). We compared medication adherence and persistence measured by proportion of days covered (PDC) and treatment duration of index AAP, all-cause and psychiatric hospital care (hospitalization or emergency department visit), and medical costs during 6-month follow-up. Models performed included logistic regression for hospital care, linear regression for PDC and cost, and Cox proportional hazards regression for time to discontinuation, adjusting for demographic, clinical, and utilization differences during the 6 months before index AAP. FINDINGS The total sample included 778 brexpiprazole, 626 lurasidone, and 3458 quetiapine therapy initiators. Adjusting for baseline differences, the risk of discontinuation of index AAP was statistically significantly higher for quetiapine than for brexpiprazole (hazard ratio [HR] = 1.13; 95% CI, 1.02-1.25; P = 0.023) and did not differ between lurasidone and brexipiprazole (HR = 1.14; 95% CI, 1.00-1.29; P = 0.054). The adjusted rate of all-cause hospitalization or emergency department visit in the postindex period was lowest for brexpiprazole at 27.4% (95% CI, 24.0%-31.0%), compared with 31.1% (95% CI, 27.3%-35.2%) for lurasidone and 35.3% (95% CI, 33.5%-37.1%) for quetiapine (P< 0.001 for all comparisons). Quetiapine users had increased all-cause costs compared with brexpiprazole users (estimate = $2309; 95% CI, $31-$4587; P = 0.047); all-cause medical costs did not differ between lurasidone and brexpiprazole (estimate = $913; 95% CI, $-2033 -$3859; P = 0.543). Adjusted psychiatric hospital care, psychiatric costs, and PDC did not differ significantly among the groups. IMPLICATIONS In patients with MDD and a variety of insurance types, brexpiprazole use was associated with statistically significantly lower risks of discontinuation, risk of hospital care (hospitalization and ED visits), and all-cause medical costs compared with adjunctive quetiapine. Differences between brexpiprazole and lurasidone were not statistically significant. These findings suggest that drug choice is associated with subsequent health care utilization and costs.
Collapse
Affiliation(s)
- Michael S Broder
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Mallik Greene
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, USA.
| | - Tingjian Yan
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | - Eunice Chang
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| | | | - Irina Yermilov
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA, USA
| |
Collapse
|
18
|
Abstract
AIMS This study explored the association between medication adherence to oral atypical antipsychotics (AAP) and both psychiatric hospitalization and associated costs in bipolar I disorder (BD-I) in a real-world setting. MATERIALS AND METHODS This retrospective study used the Truven Health MarketScan Medicaid, Commercial, and Medicare Supplemental Claims Databases. Adults were identified if they had BD-I and initiated an AAP treatment during the study identification period (July 1, 2015-June 30, 2016 for Medicaid, July 1, 2015-March 31, 2016 for Commercial and Medicare Supplemental) and had ≥6-month continuous enrollment before (baseline) and after (follow-up) the first day of treatment. Medication adherence was measured by the proportion of days covered (PDC) and grouped as: fully-adherent (PDC ≥80%), partially-adherent (40% ≤ PDC <80%), and non-adherent (PDC <40%). Logistic and linear regression models were conducted to estimate the risk of psychiatric hospitalization and costs during the 6-month follow-up period. RESULTS The final sample consisted of 5,892 (32.0%) fully-adherent, 4,246 (23.1%) partially-adherent, and 8,250 (44.9%) non-adherent patients. The adjusted rate of psychiatric hospitalization during the follow-up period was lower in the fully-adherent (6.0%) vs partially- (8.3%) or non-adherent (8.8%) groups (p < 0.001). Using the fully-adherent cohort as the reference group, the odds of psychiatric hospitalization were significantly higher for the partially-adherent (OR = 1.42; 95% CI = 1.23-1.64) and non-adherent (1.51; 1.33-1.71) cohorts. The mean adjusted psychiatric hospitalization cost over 6 months among hospitalized patients was lower for the fully-adherent cohort ($11,748), than the partially-adherent ($15,051 p = 0.002) or non-adherent cohorts ($13,170, not statistically significant). LIMITATIONS The medication adherence measures relied on prescription claims data, not actual use. CONCLUSIONS In the treatment of BD-I, better medication adherence to AAP was associated with fewer psychiatric hospitalizations. Among hospitalized patients, fully-adherent patients had statistically significantly lower psychiatric costs than partially-adherent ones. These findings suggest that improving adherence to AAP in BD-I may be a valuable goal from both clinical and economic perspectives.
Collapse
Affiliation(s)
- Michael S Broder
- a Partnership for Health Analytic Research (PHAR), LLC , Beverly Hills , CA , USA
| | - Mallik Greene
- b Otsuka Pharmaceutical Development & Commercialization, Inc. , Princeton , NJ , USA
| | - Eunice Chang
- a Partnership for Health Analytic Research (PHAR), LLC , Beverly Hills , CA , USA
| | | | - Tingjian Yan
- a Partnership for Health Analytic Research (PHAR), LLC , Beverly Hills , CA , USA
| | - Irina Yermilov
- a Partnership for Health Analytic Research (PHAR), LLC , Beverly Hills , CA , USA
| |
Collapse
|
19
|
Yermilov I, Greene M, Chang E, Hartry A, Yan T, Broder MS. Earlier Versus Later Augmentation with an Antipsychotic Medication in Patients with Major Depressive Disorder Demonstrating Inadequate Efficacy in Response to Antidepressants: A Retrospective Analysis of US Claims Data. Adv Ther 2018; 35:2138-2151. [PMID: 30456519 PMCID: PMC6267688 DOI: 10.1007/s12325-018-0838-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Indexed: 12/28/2022]
Abstract
Introduction There is little evidence regarding the most effective timing of augmentation of antidepressants (AD) with antipsychotics (AP) in patients with major depressive disorder (MDD) who inadequately respond to first-line AD (inadequate responders). The study’s objective was to understand the association between timing of augmentation of AD with AP and overall healthcare costs in inadequate responders. Methods Using the Truven Health MarketScan® Medicaid, Commercial, and Medicare Supplemental databases (7/1/09–12/31/16), we identified adult inadequate responders if they had one of the following indicating incomplete response to initial AD: psychiatric hospitalization or emergency department (ED) visit, initiating psychotherapy, or switching to or adding on a different AD. Two mutually exclusive cohorts were identified on the basis of time from first qualifying event date to first date of augmentation with an AP (index date): 0–6 months (early add-on) and 7–12 months (late add-on). Patients were further required to be continuously enrolled 1 year before (baseline) and 1 year after (follow-up) index date. Patients with schizophrenia or bipolar disorder diagnoses were excluded. General linear regression was used to estimate adjusted healthcare costs in the early versus late add-on cohort, controlling for baseline demographic and clinical characteristics, insurance type, medications, and ED visits or hospitalizations. Results Of the 6935 identified inadequate responders, 68.7% started an AP early and 31.3% late. At baseline, before AP augmentation, patients in the early add-on cohort had higher psychiatric comorbid disease burden (47.3% vs. 42.5%; p < 0.001) and higher inpatient utilization [mean (SD) 0.41 (0.72) vs. 0.27 (0.67); p < 0.001] than in late add-on cohort. During follow-up, the adjusted total all-cause healthcare cost was significantly lower in the early vs. late add-on cohort ($18,864 vs. $20,452; p = 0.046). Conclusion Findings of this real-world study suggest that, in patients with MDD who inadequately responded to first-line AD treatment, adding an AP earlier reduces overall healthcare costs. Funding Otsuka Pharmaceutical Development and Commercialization, Inc. and Lundbeck. Electronic supplementary material The online version of this article (10.1007/s12325-018-0838-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLC, 280 S. Beverly Dr., Beverly Hills, CA, 90212, USA
| | - Mallik Greene
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center, Princeton, NJ, 08540, USA.
| | - Eunice Chang
- Partnership for Health Analytic Research (PHAR), LLC, 280 S. Beverly Dr., Beverly Hills, CA, 90212, USA
| | - Ann Hartry
- Lundbeck, LLC, 6 Parkway North, Deerfield, IL, 60015, USA
| | - Tingjian Yan
- Partnership for Health Analytic Research (PHAR), LLC, 280 S. Beverly Dr., Beverly Hills, CA, 90212, USA
| | - Michael S Broder
- Partnership for Health Analytic Research (PHAR), LLC, 280 S. Beverly Dr., Beverly Hills, CA, 90212, USA
| |
Collapse
|
20
|
Abstract
PURPOSE We evaluated the rate of hyperlipidemia identified during workplace screening in previously undiagnosed individuals, the association between workplace hyperlipidemia screening and use of medical care during follow-up, and changes in lipid profile among individuals with hyperlipidemia at screening. DESIGN Nonexperimental longitudinal study. SETTING Employees who participated in a workplace health screening. PARTICIPANTS A total of 18 993 individuals from 39 self-insured employers in the United States. MEASURES Total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides were measured during screening. A claims-based algorithm was used to identify hyperlipidemia cases. ANALYSIS Discrete-time survival analysis was used to estimate monthly rates of new hyperlipidemia diagnoses or prescriptions. Paired t tests were used to evaluate 1-year changes in lipid profile. RESULTS A total of 1872 (9.9%) individuals had hyperlipidemia at screening. Among all individuals, a significantly greater rate of new hyperlipidemia diagnoses was observed during the first month after screening, compared to the 3 months before screening (odds ratio [95% CI]: 2.99 [2.66-3.36]). Among the 987 individuals who were followed up 1 year later, significant improvements were observed in total cholesterol (-8.5% ± 13.6%) and LDL levels (-10.2% ± 19.3%). CONCLUSION Workplace health screenings in an insured population were associated with a subsequent increase in physician visits and prescriptions for hyperlipidemia. After 1 year, significant improvements in total cholesterol and LDL levels were observed among individuals who screened positive for hyperlipidemia.
Collapse
Affiliation(s)
| | | | | | - Antonio P Legorreta
- 3 Department of Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
21
|
Bali V, Yermilov I, Coutts K, Legorreta AP. Novel screening metric for the identification of at-risk peripheral artery disease patients using administrative claims data. Vasc Med 2015; 21:33-40. [PMID: 26608733 DOI: 10.1177/1358863x15616687] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 12/13/2022]
Abstract
Despite high morbidity and mortality associated with peripheral artery disease (PAD), it remains under-diagnosed and under-treated. The objective of this study was to develop a screening metric to identify undiagnosed patients at high risk of developing PAD using administrative data. Commercial claims data from 2010 to 2012 were utilized to develop and internally validate a PAD screening metric. Medicare data were used for external validation. The study population included adults, aged 30 years or older, with new cases of PAD identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis/procedure codes or the Healthcare Common Procedure Coding System (HCPCS) codes. Multivariate logistic regression was conducted to determine PAD risk factors used in the development of the screening metric for the identification of at-risk PAD patients. The cumulative incidence of PAD was 6.6%. Sex, age, congestive heart failure, hypertension, chronic renal insufficiency, stroke, diabetes, acute myocardial infarction, transient ischemic attack, hyperlipidemia, and angina were significant risk factors for PAD. A cut-off score of ⩾20 yielded sensitivity, specificity, positive predictive value, negative predictive value, and c-statistics of 83.5%, 60.0%, 12.8%, 98.1%, and 0.78, respectively. By identifying patients at high risk for developing PAD using only administrative data, the use of the current pre-screening metric could reduce the number of diagnostic tests, while still capturing those patients with undiagnosed PAD.
Collapse
Affiliation(s)
- Vishal Bali
- Health Advocate, Inc., Westlake Village, CA, USA
| | | | - Kayla Coutts
- Health Advocate, Inc., Westlake Village, CA, USA
| | - Antonio P Legorreta
- Health Advocate, Inc., Westlake Village, CA, USA University of California, Los Angeles, School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
22
|
Broder MS, Yermilov I, Ko CY, Maggard Gibbons M, Chang E, Bentley TG, Cherepanov D, Hsiao WC, Keeler EB. The cost-effectiveness of improving cancer screening compliance. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.6057] [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
6057 Background: Expensive treatments and a growing number of cancer patients have resulted in increased spending on cancer care. Within a framework we developed for measuring the value of quality improvement (QI), we describe the cost-effectiveness of improving compliance with cancer screening measures compared to other quality measures. Methods: We used our framework to examine 18 Healthcare Effectiveness Data and Information Set (HEDIS) 2010 quality measures, synthesize related cost-effectiveness (CE) data and describe measure-specific QI-adjusted incremental cost-effectiveness ratios (ICERs). For each measure we: 1) quantified current compliance; 2) reviewed literature for ICERs; 3) estimated per-person steady state cost and quality-adjusted life years (QALYs); 4) estimated affected population size; 5) estimated the cost of QI; and 6) calculated QI-adjusted ICERs at full compliance, defined as 95%. We assumed per-person QI costs did not change with compliance and varied this in sensitivity analyses. We compared QI-adjusted ICERs for 3 cancer screening measures to the remaining measures. Results: Published ICERs for the cancer screening measures were $43,180/QALY (breast), $5,102/QALY (cervix) and $15,173/QALY (colon) and for other measures from $195/QALY (drug treatment) to $35,616/QALY (flu shots). Incorporating QI costs for cancer screening measures gave QI-adjusted ICERs of $64,549/QALY (breast), $15,463/QALY (cervix) and $22,991/QALY (colon), respectively. Incorporating QI costs for all 18 measures resulted in QI-adjusted ICERs from $195/QALY (drug treatment) to $9,075,868/QALY(antidepressant management), with a median of $15,463/QALY. Reaching 95% compliance with the 3 cancer measures would cost $5.1 billion and add 160,000 QALYs ($32,640/QALY) and with all 18 measures would cost $13.4 billion and add 5.8 million QALYs ($2,313/QALY). Conclusions: Improving compliance with cancer screening may be cost-effective at a threshold of $50k/QALY, although improving care on all HEDIS measures may be even more cost-effective. Accurate assessment of the cost of increasing cancer screening requires integration of both the cost-effectiveness of the screening tests and the cost of the QI programs needed to change practice.
Collapse
Affiliation(s)
| | - Irina Yermilov
- UCLA Center for Surgical Outcomes and Quality, Los Angeles, CA
| | - Clifford Y. Ko
- UCLA Center for Surgical Outcomes and Quality, Los Angeles, CA
| | | | - Eunice Chang
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Tanya G. Bentley
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Dasha Cherepanov
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Wendy C. Hsiao
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | | |
Collapse
|
23
|
Abstract
BACKGROUND Hospital readmissions among patients with diabetes are substantial and costly. Although prior studies have shown that receipt of outpatient quality of care significantly reduces the risk of hospitalization among patients with diabetes, little is known about its impact on hospital readmission. The objective of this study is to assess the impact of outpatient quality of care on 30-day readmission among patients with diabetes. METHODS We used deidentified administrative claims data from the IMS LifeLink and included commercially insured diabetes patients ≥ 19 years old discharged from hospitals in the United States in 2009 and 2010 (n = 30,139). The outcome was readmission within 2-30 days of discharge. The main independent variables were receipt of outpatient quality-of-care measures (i.e., two hemoglobin A1c tests, low-density lipoprotein (LDL) test, 90-day supply of statin, and 90-day supply of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). Multivariate logistic regression was used to examine the impact of outpatient quality of care on hospital readmission while controlling for demographics, clinical characteristics, health care utilization, and insurance type in the year prior to admission. RESULTS Overall 30-day readmission rates among patients with diabetes were 18.9%. Patients who received at least one LDL test [odds ratio (OR) = 0.918, 95% confidence interval (CI; 0.852 0.989), p < .025] and ≥90-day supply of statins (OR = 0.91, 95% CI [0.85 0.97], p < .01) were less likely to be readmitted to the hospital. CONCLUSIONS Receipt of LDL testing and adherence to statin medications were effective in decreasing the likelihood of 30-day hospital readmission and may be considered as elements of a quality focused incentive-based health care delivery package for diabetes patients.
Collapse
Affiliation(s)
| | - Qiufei Ma
- IMS HealthWoodland Hills, California
| | - Hua Chen
- Texas Tech University Health SciencesLubbock, Texas
| | | |
Collapse
|
24
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Gibbons MM. Patient behaviors associated with weight regain after laparoscopic gastric bypass. Obes Res Clin Pract 2011; 5:e169-266. [DOI: 10.1016/j.orcp.2011.03.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 02/21/2011] [Accepted: 03/10/2011] [Indexed: 02/05/2023]
|
25
|
Chen JY, Tian H, Juarez DT, Yermilov I, Braithwaite RS, Hodges KA, Legorreta A, Chung RS. Does Pay for Performance Improve Cardiovascular Care in a “Real-World” Setting? Am J Med Qual 2011; 26:340-8. [DOI: 10.1177/1062860611398303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Deborah Taira Juarez
- Hawaii Medical Service Association, Honolulu, HI
- University of Hawaii at Manoa, Honolulu, HI
| | | | | | | | - Antonio Legorreta
- IMS Health, Woodland Hills, CA
- University of California, Los Angeles, Los Angeles, CA
| | | |
Collapse
|
26
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Shekelle PG, Gibbons MM. Is social support associated with greater weight loss after bariatric surgery?: a systematic review. Obes Rev 2011; 12:142-8. [PMID: 20158617 DOI: 10.1111/j.1467-789x.2010.00720.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [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: 11/30/2022]
Abstract
Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post-operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988-2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post-operative weight loss (total n = 735 patients). All studies found a positive association between post-operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non-significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post-operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post-operative outcomes.
Collapse
Affiliation(s)
- M Livhits
- Department of Surgery, David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Chen F, Puig M, Yermilov I, Malin J, Schneider EC, Epstein AM, Kahn KL, Ganz PA, Gibbons MM. Using breast cancer quality indicators in a vulnerable population. Cancer 2011; 117:3311-21. [PMID: 21264846 DOI: 10.1002/cncr.25915] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 11/16/2010] [Accepted: 12/02/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adherence to quality indicators may be especially important to disease-specific outcomes for uninsured, vulnerable patients. The objective of this study was to measure adherence to National Initiative for Cancer Care Quality (NICCQ) breast cancer quality indicators in a public hospital and compare performance to published rates in a previously collected 5-city cohort. METHODS One hundred five consecutive, newly diagnosed, stage I-III, breast cancer patients at a public hospital (from 2005 to 2007) were identified. Adherence rates to 31 quality indicators were measured by using medical record abstraction. Rates were calculated for individual indicators, aggregated domains, and components of care and were compared with the 5-city cohort results by using a 2-sided test of proportions. RESULTS Overall adherence to the NICCQ indicators at the public hospital was 82%, versus 86% in the 5-city cohort. Public hospital adherence was better in 3 domains and components (Management of Treatment Toxicity 95% vs 73%, Referrals 76% vs 15%, and Documentation of Key Clinical Factors 72% vs 64%, P < .05 for all), but it was lower in others (Testing 82% vs 96%, Adjuvant Therapy 76% vs 83%, Surgery 72% vs 86%, Surveillance 63% vs 94%, and Respect for Patient Preferences 52% vs 72%, P < .001 for all). CONCLUSIONS The results showed that it is possible to deliver breast cancer care to vulnerable patients comparable in quality to the care received by the broader population. Further study should identify the factors that lead to variation in adherence across domains of quality.
Collapse
Affiliation(s)
- Formosa Chen
- Department of Surgery, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Chen JY, Kang N, Juarez DT, Yermilov I, Braithwaite RS, Hodges KA, Legorreta A, Chung RS. Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year. J Healthc Qual 2011; 33:29-36. [PMID: 21733022 DOI: 10.1111/j.1945-1474.2010.00124.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.
Collapse
|
29
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Gibbons MM. Behavioral Factors Associated with Successful Weight Loss after Gastric Bypass. Am Surg 2010. [DOI: 10.1177/000313481007601027] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients undergoing bariatric surgery lose substantial weight (≥50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as ≥50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 ± 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.
Collapse
Affiliation(s)
- Masha Livhits
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Cheryl Mercado
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Irina Yermilov
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Janak A. Parikh
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Erik Dutson
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Amir Mehran
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Clifford Y. Ko
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Melinda Maggard Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Surgery, Olive View-University of California, Los Angeles, Sylmar, California
| |
Collapse
|
30
|
Abstract
The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators ( P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.
Collapse
Affiliation(s)
- Formosa Chen
- Olive View–UCLA Medical Center, Sylmar, California
- Departments of Surgery and University of California, Los Angeles, California
- Greater West Los Angeles Veterans Administration, Los Angeles, California
| | - Cheryl Mercado
- Departments of Surgery and University of California, Los Angeles, California
- Greater West Los Angeles Veterans Administration, Los Angeles, California
| | | | - Melissa Puig
- Olive View–UCLA Medical Center, Sylmar, California
| | - Clifford Y. Ko
- Departments of Surgery and University of California, Los Angeles, California
- Greater West Los Angeles Veterans Administration, Los Angeles, California
| | - Katherine L. Kahn
- Departments of Medicine, University of California, Los Angeles, California
| | - Patricia A. Ganz
- Departments of Medicine, University of California, Los Angeles, California
| | - Melinda Maggard Gibbons
- Olive View–UCLA Medical Center, Sylmar, California
- Departments of Surgery and University of California, Los Angeles, California
- Greater West Los Angeles Veterans Administration, Los Angeles, California
| |
Collapse
|
31
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Gibbons MM. Behavioral factors associated with successful weight loss after gastric bypass. Am Surg 2010; 76:1139-1142. [PMID: 21105629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Patients undergoing bariatric surgery lose substantial weight (> or = 50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as > or =50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 +/- 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.
Collapse
Affiliation(s)
- Masha Livhits
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, 10833 LeConte Avenue, 72 215 CHS, Los Angeles, CA 90095, USA.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Chen F, Mercado C, Yermilov I, Puig M, Ko CY, Kahn KL, Ganz PA, Gibbons MM. Improving breast cancer quality of care with the use of patient navigators. Am Surg 2010; 76:1043-1046. [PMID: 21105605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.
Collapse
Affiliation(s)
- Formosa Chen
- Olive View-UCLA Medical Center, Sylmar, California, USA
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Mercado C, Livhits M, Yermilov I, Parikh J, Ko CY, Gibbons MM. P-46: Is binge eating disorder associated with the degree of weight loss following bariatric surgery? Surg Obes Relat Dis 2010. [DOI: 10.1016/j.soard.2010.03.248] [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: 10/19/2022]
|
34
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Gibbons MM. Exercise following bariatric surgery: systematic review. Obes Surg 2010; 20:657-65. [PMID: 20180039 PMCID: PMC2850994 DOI: 10.1007/s11695-010-0096-0] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 01/28/2010] [Indexed: 02/05/2023]
Abstract
The contribution of physical activity on the degree of weight loss following bariatric surgery is unclear. To determine impact of exercise on postoperative weight loss. Medline search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened articles, 14 reported on exercise and weight loss outcomes. The most commonly used instruments to measure activity level were the Baecke Physical Activity Questionnaire, the International Physical Activity Questionnaire, and a variety of self-made questionnaires. The definition of an active patient varied but generally required a minimum of 30 min of exercise at least 3 days per week. Thirteen articles reported on exercise and degree of postoperative weight loss (n = 4,108 patients). Eleven articles found a positive association of exercise on postoperative weight loss, and two did not. Meta-analysis of three studies revealed a significant increase in 1-year postoperative weight loss (mean difference = 4.2% total body mass index (BMI) loss, 95% confidence interval (CI; 0.26–8.11)) for patients who exercise postoperatively. Exercise following bariatric surgery appears to be associated with a greater weight loss of over 4% of BMI. While a causal relationship cannot be established with observational data, this finding supports the continued efforts to encourage and support patients’ involvement in post-surgery exercise. Further research is necessary to determine the recommended activity guidelines for this patient population.
Collapse
Affiliation(s)
- Masha Livhits
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 LeConte Ave, 72-215 CHS, Los Angeles, CA 90095, USA.
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
Careful selection of bariatric patients is critical for successful outcomes. In 1991, the NIH first established patient selection guidelines; however, some surgeons operate on individuals outside of these criteria, i.e., extreme age groups. We developed appropriateness criteria for the spectrum of patient characteristics including age, BMI, and severity of eight obesity-related comorbidities. Candidate criteria were developed using combinations of patient characteristics including BMI: > or =40 kg/m(2), 35-39, 32-34, 30-31, <30; age: 12-18, 19-55, 56-64, 65+ years old; and comorbidities: prediabetes, diabetes, hypertension, dyslipidemia, sleep apnea, venous stasis disease, chronic joint pain, and gastroesophageal reflux (plus severity level). Criteria were formally validated on their appropriateness of whether the benefits of surgery clearly outweighed the risks, by an expert panel using the RAND/UCLA modified Delphi method. Nearly all comorbidity severity criteria for patients with BMI > or =40 kg/m(2) or BMI = 35-39 kg/m(2) in intermediate age groups were found to be appropriate for surgery. In contrast, patients in the extreme age categories were considered appropriate surgical candidates under fewer conditions, primarily the more severe comorbidities, such as diabetes and hypertension. For patients with a BMI of 32-34, only the most severe category of diabetes (Hgb A1c >9, on maximal medical therapy), is an appropriate criterion for those aged 19-64, whereas many mild to moderate severity comorbidity categories are "inappropriate." There is overwhelming agreement among the panelists that the current evidence does not support performing bariatric surgery in lower BMI individuals (BMI <32). This is the first development of appropriateness criteria for bariatric surgery that includes severity categories of comorbidities. Only for the most severe degrees of comorbidities were adolescent and elderly patients deemed appropriate for surgery. Patient selection for bariatric procedures should include consideration of both patient age and comorbidity severity.
Collapse
Affiliation(s)
- Irina Yermilov
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | | | | | | | | |
Collapse
|
36
|
Yermilov I, Jain S, Sekeris E, Bentrem DJ, Hines OJ, Reber HA, Ko CY, Tomlinson JS. Utilization of parenteral nutrition following pancreaticoduodenectomy: is routine jejunostomy tube placement warranted? Dig Dis Sci 2009; 54:1582-8. [PMID: 18958617 DOI: 10.1007/s10620-008-0526-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [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] [Received: 06/16/2008] [Accepted: 09/01/2008] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Complications following pancreaticoduodenectomy (PD) often necessitate nutritional support. This study analyzes the utilization of parenteral nutrition (TPN) during the surgical admission as evidence for or against routine jejunostomy placement. METHODS The California Cancer Registry (1994-2003) was linked to the California Inpatient File; PD for adenocarcinoma was performed in 1,873 patients. TPN use and enterostomy tube placement were determined and preoperative characteristics predictive of TPN use during the surgical admission were identified. RESULTS Fourteen percent of patients received TPN, 23% underwent enterostomy tube placement, and 63% received no supplemental nutritional support. TPN was associated with longer hospital stay (18 vs. 13 days, P < 0.0001). The Charlson Comorbidity Index (CCI) > or = 3 had nearly two-fold greater odds of receiving TPN (odds ratio [OR] = 1.85, P < 0.005). CONCLUSION Approximately 1 in 6 patients undergoing PD received TPN, which was associated with prolonged hospital stay. CCI > or = 3 was associated with increased odds of TPN utilization. Selected jejunostomy placement in patients with high CCI is worthy of consideration.
Collapse
Affiliation(s)
- Irina Yermilov
- Department of Surgery, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Livhits M, Mercado C, Yermilov I, Parikh JA, Maggard-Gibbons M. IH-110: Predictors of weight loss following bariatric surgery: A systematic review. Surg Obes Relat Dis 2009. [DOI: 10.1016/j.soard.2009.03.189] [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: 10/20/2022]
|
38
|
Abstract
Evaluation of 12 lymph nodes has been mandated to prevent colon cancer understaging. Given that the probability of node metastases is largely associated with T-stage, are <12 nodes substandard for T1 and T2 lesions? We evaluated if survival for T1 and T2 tumors varies by nodes examined. In SEER, 61,237 patients undergoing colon cancer resection were identified. For each T-stage, 5-year survival rates were compared for node-negative cancers by using stepwise node cut-point comparisons (4 nodes, <4, etc.). Survival impact was determined by log-rank test and hazard regression. For T1 tumors, 4 nodes had 24% lower hazard of death compared to <4. For T2 tumors, 10 nodes had the biggest survival impact, 15% lower hazard of death. In conclusion, the number of nodes to stage T1 and T2 lesions may be <12.
Collapse
Affiliation(s)
- Melinda A Maggard
- Department of Surgery, Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA.
| | | | | | | |
Collapse
|
39
|
Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L, Santry HP, Morton JM, Livingston EH, Shekelle PG. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300:2286-96. [PMID: 19017915 DOI: 10.1001/jama.2008.641] [Citation(s) in RCA: 302] [Impact Index Per Article: 18.9] [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] [Indexed: 02/03/2023]
Abstract
CONTEXT Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age. OBJECTIVES To estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery. EVIDENCE ACQUISITION Search of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery. EVIDENCE SYNTHESIS Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group. Findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences in neonatal outcomes were found after gastric bypass compared with nonobese controls (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported [1 study] and P = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = not reported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1 study] and P = .28 [1 study]). Findings were supported by 10 other studies. Studies regarding nutrition, fertility, cesarean delivery, and contraception were limited. CONCLUSION Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.
Collapse
|
40
|
Yermilov I, Bentrem D, Sekeris E, Jain S, Maggard MA, Ko CY, Tomlinson JS. Readmissions following pancreaticoduodenectomy for pancreas cancer: a population-based appraisal. Ann Surg Oncol 2008; 16:554-61. [PMID: 19002528 DOI: 10.1245/s10434-008-0178-6] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 08/20/2008] [Accepted: 08/23/2008] [Indexed: 01/07/2023]
Abstract
Procedure complexity and volume-outcome relationships have led to increased regionalization of pancreaticoduodenectomy (PD) for pancreas cancer. Knowledge regarding outcomes after PD comes from single-institutional series, which may be limited if a significant number of patients follow up at other hospitals. Thus, readmission data may be underreported. This study utilizes a population-based data set to examine readmission data following PD. California Cancer Registry (1994-2003) was linked to the California's Office of Statewide Health Planning and Development (OSHPD) database; patients with pancreatic adenocarcinoma who had undergone PD, excluding perioperative (30-day) mortality, were identified. All hospital readmissions within 1 year following PD were analyzed with respect to timing, location, and reason for readmission. Our cohort included 2,023 patients who underwent PD for pancreas cancer. Fifty-nine percent were readmitted within 1 year following PD and 47% were readmitted to a secondary hospital. Readmission was associated with worse median survival compared with those not readmitted (10.5 versus 22 months, p<0.0001). Multivariate analysis revealed that increasing T-stage, age, and comorbidities were associated with increased likelihood of readmission. Diagnoses associated with high rates of readmission included progression of disease (24%), surgery-related complications (14%), and infection (13%). Diabetes (1.4%) and pain (1.5%) were associated with low rates of readmission. We found a readmission rate of 59%, which is much higher than previously reported by single institutional series. Concordantly, nearly half of patients readmitted were readmitted to a secondary hospital. Common reasons for readmission included progression of disease, surgical complications, and infection. These findings should assist in both anticipating and facilitating postoperative care as well as managing patient expectations. This study utilizes a novel population-based database to evaluate incidence, timing, location, and reasons for readmission within 1 year following pancreaticoduodenectomy. Fifty-nine percent of patients were readmitted within 1 year after pancreaticoduodenectomy and 47% were readmitted to a secondary hospital.
Collapse
Affiliation(s)
- Irina Yermilov
- Department of Surgery, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | | | | | | | | | | | | |
Collapse
|
41
|
Shekelle PG, Newberry S, Maglione M, Li Z, Yermilov I, Hilton L, Suttorp M, Maggard M, Carter J, Tringale C, Chen S. Bariatric surgery in women of reproductive age: special concerns for pregnancy. Evid Rep Technol Assess (Full Rep) 2008:1-51. [PMID: 20731480 PMCID: PMC4780974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
CONTEXT The use of bariatric surgery for treating severe obesity has increased dramatically over the past 10 years; about half of patients who undergo these procedures are women of reproductive age. This report was commissioned to measure the incidence of bariatric surgery in this population and review the evidence on the impact of bariatric surgery on fertility and subsequent pregnancy. OBJECTIVES To measure the incidence of contemporary bariatric surgery procedures in women age 18-45 and to assess its impact on fertility, contraception, prepregnancy risk factors, and pregnancy outcomes, including those of neonates. DATA SOURCES AND STUDY SELECTION Nationwide Inpatient Sample (NIS), a national sample of over 1,000 hospitals, to measure the trend in the number of women of reproductive age who underwent bariatric procedures from 1998-2005. We searched numerous electronic databases, including MEDLINE and Embase, for potentially relevant studies involving bariatric surgery (gastric bypass, laparoscopic adjustable gastric band, vertical-banded gastroplasty, biliopancreatic diversion), and consequent fertility, contraception, pregnancy, weight management, maternal and neonatal outcomes, and nutritional deficiencies. We scanned reference lists for additional relevant articles and contacted experts in the fields of bariatric surgery and obstetrics/gynecology (OB/GYN). Of 223 screened articles, we accepted 57 that reported on fertility following surgery (19 articles), contraception use/recommendations (11), maternal weight or nutrition management (28), maternal outcomes including morbidity and mortality (48), cesarean-section rates (16), and neonatal outcomes (44). These articles included reports on gastric bypass, both open and laparoscopic (27 articles), laparoscopic adjustable band (15), biliopancreatic diversion (16), and vertical-banded gastroplasty (6). Studies could contribute to one or more analyses. We found one case-control study and the observational data accepted included 12 cohort studies, 21 case series, and 23 individual case reports. DATA EXTRACTION We abstracted information about study design, fertility history, fertility outcomes, prepregnancy weight loss, nutritional management, outcomes following pregnancy, and adverse events (during pregnancy) related to surgery. DATA SYNTHESIS Nationally representative data showed a six-fold increase in bariatric surgery inpatient procedures from 1998 to 2005. Women age 18-45 accounted for about half of the patients undergoing bariatric surgery; over 50,000 have these procedures as inpatients annually. An unknown number have outpatient bariatric procedures. We identified one case-control study that directly addressed some of the key questions, but no randomized controlled trials or prospective cohort studies, which would be the strongest study designs to answer questions about effectiveness, risk and prognosis. Consequently, all of our conclusions are limited by the available data, and are cautious.The evidence suggests that bariatric surgery results in improved fertility; the strongest evidence is in women with the polycystic ovarian syndrome, where biochemical studies showing normalization of hormones after surgery support case series data. Observational studies (retrospective cohorts and case series) suggest that fertility improves following bariatric procedures and weight loss; similar to that seen when obese women lose weight through nonsurgical means. There is almost no evidence on post-surgical contraceptive efficacy or use. Research is needed to determine whether differences in absorption, particularly for oral contraceptives, affect contraceptive efficacy. Nutrient deficiencies were reported in infants born to women who underwent procedures that resulted in malabsorption, as well as women who did not take prenatal vitamins or had difficulty with their own nutrition (i.e., from chronic vomiting). Literature suggests that gastric bypass and laparoscopic adjustable band procedures confer only minimal, if any, increased risk of nutritional or congenital problems if supplemental vitamins are taken and maternal nutrition is otherwise adequate. Biliopancreatic diversion has an appreciable risk for nutritional problems in some patients. Women who have undergone bariatric surgery may have less risk than obese women for certain pregnancy complications such as gestational diabetes, preeclampsia, and pregnancy induced hypertension. There is no evidence that cesarean section rates and delivery complications are higher in the post-surgery group, but data are limited. CONCLUSIONS Weight loss procedures are being performed more frequently to treat morbid obesity, with a six-fold increase over a recent 7-year time span; almost half of all patients are women of reproductive age. The level of evidence on fertility, contraception, and pregnancy outcomes is limited to observational studies. Data suggest that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic adjustable band and gastric bypass as long as adequate maternal nutrition and vitamin supplementation are maintained. There is no evidence that delivery complications are higher in post-surgery pregnancies.
Collapse
Affiliation(s)
- Paul G Shekelle
- Southern California Evidence-based Practice Center, Santa Monica, CA, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Yermilov I, Chow W, Devgan L, Makary M, Ko CY. How to measure the quality of surgery-related web sites. Am Surg 2008; 74:997-1000. [PMID: 18942631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Appropriateness and adequacy of health information on the Internet varies. Given there is no validated instrument for web site evaluation focusing on elective general surgical procedures, our goal was to create a composite score as a web site quality rating system. The components of a composite score were developed through a literature review and included Agency for Healthcare Research and Quality guidelines of "Having Surgery? What You Need to Know" and previously published health-related web site scales. All criteria are given equal weight (0/1 scale). The composite score is reported as a percentage of a total possible 16 points. To pilot the rating scale, a web search for roux-en-y gastric bypass (RYGB) was used. Validation compared the composite score with an evaluation by surgeons. Mean composite score for 18 RYGB web sites was 48 per cent (range, 19% to 75%). Composite score validation used a cutoff value of 50 per cent. There was 100 per cent agreement (kappa = 1.0) between composite and surgeon scores. This is the first validated comprehensive composite score to evaluate the web site quality for patients undergoing elective surgery. This score shows promise in increasing efficiency of surgical practices by providing a way in which we can evaluate web sites and encourage our patients to become well informed by reading only high-quality web sites.
Collapse
Affiliation(s)
- Irina Yermilov
- Department of Surgery, Greater West Los Angeles VA Healthcare System, Los Angeles, California, USA.
| | | | | | | | | |
Collapse
|
43
|
Yermilov I, Chow W, Devgan L, Makary MA, Ko CY. What is the quality of surgery-related information on the internet? Lessons learned from a standardized evaluation of 10 common operations. J Am Coll Surg 2008; 207:580-6. [PMID: 18926463 DOI: 10.1016/j.jamcollsurg.2008.04.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 04/29/2008] [Accepted: 04/30/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although there is high-quality information on the Internet, it is difficult for patients to identify high-quality Web sites from those with inaccurate or misleading information. Our goal was to determine specific characteristics of Web search results that yield high-quality information and can be discerned easily by patients. STUDY DESIGN A validated rating system was used to evaluate surgical Web sites for appropriateness and adequacy. Web sites were identified using three search term types (technical, descriptive, and layperson) for 10 common surgical procedures. The top three sponsored (paid) and unsponsored (unpaid) Web site matches were identified. The search and analysis were repeated 1 month later. RESULTS One hundred forty-five Web sites were retrieved: 90 unsponsored and 55 sponsored. Unsponsored sites had higher mean composite scores than sponsored Web sites (50.6% versus 25%, p < 0.0001). Searches using layperson terms had lower mean composite scores compared with those using technical terms (36.9% versus 47.5%, p < 0.02). Professional Web sites had the highest mean composite scores (66.3%); legal Web sites had the lowest (6.3%). On regression analysis, unsponsored Web sites were associated with higher composite scores (p < 0.0001); number 1 match results (p < 0.02) and using layperson search terms (p < 0.052) were associated with lower mean composite scores. Repeat search results demonstrated no significant differences, except number 3 match results were no longer significant. CONCLUSIONS To optimize patients' Web searches, surgeons should recommend unsponsored sites; suggest professional society sites, if available; and provide technical search terms. But information on some topics, such as risks of not undergoing surgery, remains poor and requires discussion between the surgeon and patient.
Collapse
Affiliation(s)
- Irina Yermilov
- Department of Surgery, Greater West Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | | | | | | | | |
Collapse
|
44
|
Parikh J, Yermilov I, Mcgory M, Jain S, Ko CY, Maggard M. Is High BMI Associated with Specific Complications after Laparoscopic Roux-en-Y Gastric Bypass? Am Surg 2007. [DOI: 10.1177/000313480707301005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Controversy remains whether patients with body mass index (BMI) ≥ 50 kg/m2 experience more complications after laparoscopic Roux-en-y gastric bypass (LRYGB) than those with a lower BMI. Whether BMI ≥ 50 kg/m2 is associated with specific complications remains unknown. Charts of 152 patients who underwent LRYGB were reviewed. Logistic regression was used to determine whether high BMI is associated with minor or major complications. Overall, there was a trend that major complications occurred more frequently in patients with BMI ≥ 50 compared with BMI < 50, (30.4% vs 19.8%, P = 0.138). Major bleeding complications occurred in 16.1 per cent of high BMI patients as compared with 5.2 per cent with lower BMI ( P = 0.025). Multivariate regression found that BMI ≥ 50 was associated with higher odds of a major technical complication (OR = 2.73, P = 0.04), particularly for bleeding complications (odds ratio [OR] = 5.59, P = 0.01). Male gender was also associated with higher odds of a major technical complication (OR = 3.43, P = 0.04). These results suggest that high BMI patients may be better candidates for other types of weight loss surgery, such as staged procedures, and that surgeons early in their career should operate on patients with lower BMI.
Collapse
Affiliation(s)
- Janak Parikh
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Irina Yermilov
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Marcia Mcgory
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Sushma Jain
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Clifford Y. Ko
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
- Department of Surgery, Greater West Los Angeles VA Healthcare System, Los Angeles, California
| | - Melinda Maggard
- Department of Surgery, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| |
Collapse
|
45
|
Parikh J, Yermilov I, McGory M, Jain S, Ko CY, Maggard M. Is high BMI associated with specific complications after laparoscopic Roux-en-Y gastric bypass? Am Surg 2007; 73:959-962. [PMID: 17983056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Controversy remains whether patients with body mass index (BMI) > or =50 kg/m2 experience more complications after laparoscopic Roux-en-y gastric bypass (LRYGB) than those with a lower BMI. Whether BMI > or =50 kg/m2 is associated with specific complications remains unknown. Charts of 152 patients who underwent LRYGB were reviewed. Logistic regression was used to determine whether high BMI is associated with minor or major complications. Overall, there was a trend that major complications occurred more frequently in patients with BMI > or =50 compared with BMI < 50, (30.4% vs. 19.8%, P = 0.138). Major bleeding complications occurred in 16.1 per cent of high BMI patients as compared with 5.2 per cent with lower BMI (P = 0.025). Multivariate regression found that BMI > or =50 was associated with higher odds of a major technical complication (OR = 2.73, P = 0.04), particularly for bleeding complications (odds ratio [OR] = 5.59, P = 0.01). Male gender was also associated with higher odds of a major technical complication (OR = 3.43, P = 0.04). These results suggest that high BMI patients may be better candidates for other types of weight loss surgery, such as staged procedures, and that surgeons early in their career should operate on patients with lower BMI.
Collapse
Affiliation(s)
- Janak Parikh
- Department of Surgery, Center for the Health Sciences, Geffen School of Medicine at University of California Los Angeles, Los Angeles 90095, USA.
| | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Yermilov I, Jain S, Sekeris E, Ko C, Tomlinson J. Does resection of pancreas cancer have a palliative effect? Longterm appraisal of readmissions. J Am Coll Surg 2007. [DOI: 10.1016/j.jamcollsurg.2007.06.018] [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: 11/29/2022]
|
48
|
|