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Potnis KC, Viswanathan G, Bona RD, Ito S, Kempton CL, Pandya A, Krumholz HM, Goshua G. Cost-effectiveness of prophylactic emicizumab versus prophylactic recombinant factor VIII in patients with moderate or mild hemophilia A without inhibitors in the United States. Am J Hematol 2023; 98:E247-E250. [PMID: 37401660 DOI: 10.1002/ajh.27014] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
Prophylactic emicizumab is cost-ineffective in adults with moderate or mild hemophilia A without inhibitors at current pricing. The price of prophylactic emicizumab would need to decrease by >35% to become cost-effective in this patient population.
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Affiliation(s)
- Kunal C Potnis
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Robert D Bona
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding and Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
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Potnis KC, Huntington SF. Balancing considerations and qualifying conclusions for cost-effectiveness of therapies for relapsed/refractory follicular lymphoma. Blood Adv 2023; 7:2573-2574. [PMID: 36745098 PMCID: PMC10242627 DOI: 10.1182/bloodadvances.2023009864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 02/07/2023] Open
Affiliation(s)
| | - Scott F. Huntington
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT
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Potnis KC, Di M, Isufi I, Gowda L, Seropian SE, Foss FM, Forman HP, Huntington SF. Cost-effectiveness of chimeric antigen receptor T-cell therapy in adults with relapsed or refractory follicular lymphoma. Blood Adv 2023; 7:801-810. [PMID: 36342852 PMCID: PMC10011202 DOI: 10.1182/bloodadvances.2022008097] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/30/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
Follicular lymphoma (FL) is traditionally considered treatable but incurable. In March 2021, the US Food and Drug Administration approved the use of chimeric antigen receptor (CAR) T-cell therapy in patients with relapsed or refractory (R/R) FL after ≥2 lines of therapy. Priced at $373 000, CAR T-cell therapy is potentially curative, and its cost-effectiveness compared with other modern R/R FL treatment strategies is unknown. We developed a Markov model to assess the cost-effectiveness of third-line CAR T-cell vs standard of care (SOC) therapies in adults with R/R FL. We estimated progression rates for patients receiving CAR T-cell and SOC therapies from the ZUMA-5 trial and the LEO CReWE study, respectively. We calculated costs, discounted life years, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of CAR T-cell vs SOC therapies with a willingness-to-pay threshold of $150 000 per QALY. Our analysis was conducted from a US payer's perspective over a lifetime horizon. In our base-case model, the cost of the CAR T-cell strategy was $731 682 compared with $458 490 for SOC therapies. However, CAR T-cell therapy was associated with incremental clinical benefit of 1.50 QALYs, resulting in an ICER of $182 127 per QALY. Our model was most sensitive to the utilities associated with CAR T-cell therapy remission and third-line SOC therapies and to the total upfront CAR T-cell therapy cost. Under current pricing, CAR T-cell therapy is unlikely to be cost-effective in unselected patients with FL in the third-line setting. Both randomized clinical trials and longer term clinical follow-up can help clarify the benefits of CAR T-cell therapy and optimal sequencing in patients with FL.
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Affiliation(s)
| | - Mengyang Di
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Iris Isufi
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Lohith Gowda
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Stuart E. Seropian
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
| | - Francine M. Foss
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, CT
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, Yale University, New Haven, CT
- Yale School of Management, Yale University, New Haven, CT
| | - Scott F. Huntington
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, Yale University, New Haven, CT
- Correspondence: Scott Huntington, Division of Hematology, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, PO Box 208028, New Haven, CT 06520;
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Potnis KC, Ross JS, Aneja S, Gross CP, Richman IB. Artificial Intelligence in Breast Cancer Screening: Evaluation of FDA Device Regulation and Future Recommendations. JAMA Intern Med 2022; 182:1306-1312. [PMID: 36342705 PMCID: PMC10623674 DOI: 10.1001/jamainternmed.2022.4969] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Importance Contemporary approaches to artificial intelligence (AI) based on deep learning have generated interest in the application of AI to breast cancer screening (BCS). The US Food and Drug Administration (FDA) has approved several next-generation AI products indicated for BCS in recent years; however, questions regarding their accuracy, appropriate use, and clinical utility remain. Objectives To describe the current FDA regulatory process for AI products, summarize the evidence used to support FDA clearance and approval of AI products indicated for BCS, consider the advantages and limitations of current regulatory approaches, and suggest ways to improve the current system. Evidence Review Premarket notifications and other publicly available documents used for FDA clearance and approval of AI products indicated for BCS from January 1, 2017, to December 31, 2021. Findings Nine AI products indicated for BCS for identification of suggestive lesions and mammogram triage were included. Most of the products had been cleared through the 510(k) pathway, and all clearances were based on previously collected retrospective data; 6 products used multicenter designs; 7 products used enriched data; and 4 lacked details on whether products were externally validated. Test performance measures, including sensitivity, specificity, and area under the curve, were the main outcomes reported. Most of the devices used tissue biopsy as the criterion standard for BCS accuracy evaluation. Other clinical outcome measures, including cancer stage at diagnosis and interval cancer detection, were not reported for any of the devices. Conclusions and Relevance The findings of this review suggest important gaps in reporting of data sources, data set type, validation approach, and clinical utility assessment. As AI-assisted reading becomes more widespread in BCS and other radiologic examinations, strengthened FDA evidentiary regulatory standards, development of postmarketing surveillance, a focus on clinically meaningful outcomes, and stakeholder engagement will be critical for ensuring the safety and efficacy of these products.
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Affiliation(s)
| | - Joseph S Ross
- Section of General Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Sanjay Aneja
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Section of General Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Ilana B Richman
- Section of General Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
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Potnis KC, Gross CP, Richman IB. Industry Payments and New Breast Cancer Screening Technology Use. J Gen Intern Med 2021; 36:1440-1442. [PMID: 32468434 PMCID: PMC8131452 DOI: 10.1007/s11606-020-05771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Affiliation(s)
| | - Cary P Gross
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.,COPPER Center, Yale School of Medicine, New Haven, CT, USA
| | - Ilana B Richman
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA. .,COPPER Center, Yale School of Medicine, New Haven, CT, USA.
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Potnis KC, Flueckinger LB, Ha CI, Upadia J, Frush DP, Kishnani PS. Bone manifestations in neuronopathic Gaucher disease while receiving high-dose enzyme replacement therapy. Mol Genet Metab 2019; 126:157-161. [PMID: 30448006 DOI: 10.1016/j.ymgme.2018.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 01/15/2023]
Abstract
Avascular necrosis (AVN), one type of bone infarction, is a major irreversible complication of Gaucher disease (GD). In this report, two pediatric patients with GD type 3, homozygous for the L483P pathogenic variant (formerly L444P), developed AVN despite treatment on long-term, high-dose enzyme replacement therapy (ERT). ERT was initiated in both patients, who had intact spleens, shortly after diagnosis with an initial dramatic response. However, both patients exhibited AVN after 5.5 and 11 years on high-dose ERT, respectively, despite good compliance and normalized hematological findings and visceral symptoms. This report demonstrates the importance of careful, regular surveillance of the musculoskeletal system in addition to monitoring the neurological symptoms associated with neuronopathic GD. Additionally, it highlights the limitations of ERT in terms of targeting certain sanctuary sites such as bone marrow and suggests the need for new treatment modalities other than ERT monotherapy to address these limitations.
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Affiliation(s)
- Kunal C Potnis
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Lauren B Flueckinger
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Christine I Ha
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jariya Upadia
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Donald P Frush
- Division of Pediatric Radiology, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
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Potnis KC, Flueckinger LB, DeArmey SM, Alcalay RN, Cooney JW, Kishnani PS. Corticobasal syndrome in a man with Gaucher disease type 1: Expansion of the understanding of the neurological spectrum. Mol Genet Metab Rep 2018; 17:69-72. [PMID: 30364808 PMCID: PMC6198121 DOI: 10.1016/j.ymgmr.2018.10.001] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/07/2018] [Accepted: 10/07/2018] [Indexed: 01/02/2023] Open
Abstract
Gaucher disease (GD) is an autosomal recessive condition that results from a deficiency of the enzyme β-glucocerebrosidase. The increased risk of primary parkinsonism symptoms among individuals affected with GD and carriers for the disorder is well-documented in the literature. However, these risks and case reports often reflect patients with classical Parkinson's disease (PD) symptoms. We report a patient with GD type 1 who was diagnosed with corticobasal syndrome (CBS), a clinical atypical parkinsonism diagnosis, in his sixth decade of life. Our case highlights the need to consider forms of atypical parkinsonism such as CBS in addition to PD in the differential diagnosis of cognitive and motor changes in patients with GD type 1. We also recommend careful assessment and routine monitoring of cognition, mood, behavior, sleep patterns, olfaction, and memory in patients with GD type 1 to identify early symptoms indicative of neurological involvement.
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Affiliation(s)
- Kunal C. Potnis
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Lauren B. Flueckinger
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Stephanie M. DeArmey
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Roy N. Alcalay
- Division of Movement Disorders, Department of Neurology, Columbia University Medical Center, New York City, NY, USA
| | - Jeffrey W. Cooney
- Division of Parkinson's Disease and Movement Disorders, Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Inouye BM, Hughes FM, Jin H, Lütolf R, Potnis KC, Routh JC, Rouse DC, Foo WC, Purves JT. Diabetic bladder dysfunction is associated with bladder inflammation triggered through hyperglycemia, not polyuria. Res Rep Urol 2018; 10:219-225. [PMID: 30533402 PMCID: PMC6247963 DOI: 10.2147/rru.s177633] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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] [Indexed: 12/16/2022] Open
Abstract
Purpose Diabetes is a grave and progressive condition characterized by debilitating complications. Diabetic bladder dysfunction (DBD) is a very common complication with no specific treatments currently available. Unlike other tissues affected by this disease, the bladder is subjected to two independent insults; 1) polyuria, created by the osmotic effects of glucose in the urine, and 2) hyperglycemia itself. Based on our understanding of inflammation as a major contributor to the underlying organ damage in several other diabetic complications, its presence in the bladder during DBD and the contribution of polyuria and hyperglycemia to its development were assessed. Methods Awake, restrained cystometry was performed on wild type C57BL/6 mice and diabetic (Akita) mice on a C57BL/6 background at 15 weeks of age. A subgroup of the Akita mice were treated with phlorizin, an inhibitor of sodium-glucose linked transporter types 1 and 2 that prevents glucose reabsorption in the kidney. All groups were assessed for serum glucose, 4-hour voiding totals, and inflammation in the bladder (Evans blue assay). Results Akita mice develop cystometrically-defined DBD by 15 weeks of age, as evidenced by an increase in urinary frequency, a decrease in voiding volume, and an increase in post-voiding residual volume. Phlorizin effectively normalized serum glucose in these animals while increasing the urine output. Inflammation in the bladder was present in the diabetic animals at this time point, but not detectable in animals receiving phlorizin. Conclusion Inflammation in the bladder of diabetic mice correlates with the development of DBD and is triggered by hyperglycemia, not polyuria.
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Affiliation(s)
- Brian M Inouye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Francis M Hughes
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Bioengineering, Clemson University, Clemson, SC, USA,
| | - Huixia Jin
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Robin Lütolf
- Department of Health Science and Technology, ETH Zurich, Zürich 8092, Switzerland
| | - Kunal C Potnis
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA,
| | - Jonathan C Routh
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Douglas C Rouse
- Division of Laboratory Animal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Wen-Chi Foo
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - J Todd Purves
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA, .,Department of Bioengineering, Clemson University, Clemson, SC, USA, .,Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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